Inspection on 12/04/05 for Sovereign Lodge

This inspection was carried out on 12th April 2005.

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 10/05/07

Sovereign Lodge 23/08/06

Sovereign Lodge 02/11/05

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 NE5 1NA Lead Inspector Alan Baxter Unannounced 12 April 2005 09:30 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 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 Version 1.10 Page 3 SERVICE INFORMATION Name of service Sovereign Lodge Address Newbiggin Lane Westerhope Newcastle upon Tyne NE 5 1NA 0191 2714029 N/A N/A Mrs Jennifer Houghton Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Ms Audrey Margaret Alderson Registered Care Home 46 Category(ies) of Older People, aged 65 or over. registration, with number of places Sovereign Lodge Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 13th September 2004 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 suberb of Newcastle upon Tyne, and is quite close to local shops. It is on a bus route. Sovereign Lodge Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced during the day. The manager of the home was present during the inspection. A number of residents and staff were spoken with during the course of the inspection, which was 5 hours. The purpose of the inspection was to check the requirements made at the last inspection and to look at a range of standards. What the service does well: The home conducts thorough assessments of residents’ needs, and draws up clear care plans to meet those needs. Health care needs are closely monitored. Residents feel that they are treated well, that they are listened to, and that their privacy is respected. There is a good range of social activities for the resident group. The home welcomes relatives and other visitors. Most residents and their families are aware of the home’s complaints policy, and complaints are taken seriously. The legal rights of residents are respected, and there are policies in place to prevent abuse. The home is clean, well-maintained, warm, comfortable and safe. There are enough staff to meet the residents’ needs. The home is well managed. Sovereign Lodge Version 1.10 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 full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Sovereign Lodge Version 1.10 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 Standards Statutory Requirements Identified During the Inspection Sovereign Lodge Version 1.10 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 standard(s) 2,3. Each resident is given a written contract when they come to the home. Residents’ care needs are properly assessed before they are admitted, to make sure that the home can meet all their needs. EVIDENCE: It was a requirement of the last inspection that the home’s statement of purpose must be changed to show that the home will provide escorts for residents, where necessary. This has not been carried out. However, the home does, in practice, provide staff escorts when needed. The care records of the last two residents admitted to the home, and the assessments of a person about to be admitted, were studied. The home had carried out its own assessment of each person before admission. It had also made sure that it had received an assessment from the person’s social worker before admission. Assessments are detailed, and cover social, spiritual, psychological, skin care, risk, and nutritional needs. Sovereign Lodge Version 1.10 Page 9 Sovereign Lodge Version 1.10 Page 10 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 standard(s) 7,8,10 Each resident has an individual plan of care, to meet their assessed needs. Residents’ health care needs are fully met. Residents are treated with respect, and their privacy is also respected. EVIDENCE: The care records of six residents were examined. Care plans are drawn up on all assessed needs, with the in-house assessment format stating where a care plan has been drawn up. This is good practice. Care plans are holistic and reasonably detailed, with ’72 hour’ care plans put in place on the day of admission. All care staff are being given training in care planning. Residents’ health care needs are properly assessed and addressed. The home has started to introduce six monthly reviews of each resident’s care. Sovereign Lodge Version 1.10 Page 11 Residents spoken with said that they are happy, well cared for and treated with respect. They said that their privacy is also respected. Residents were all noticeably well-groomed. Relatives who completed ‘comments cards’ for this inspection said that the overall care is good, and that they are consulted about their relatives well being, and are kept informed by the home. Sovereign Lodge Version 1.10 Page 12 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 standard(s) 12,13. There is a reasonably varied social activities programme, and most residents are happy with the degree of social stimulation offered. Residents’ social care plans should better reflect their assessed interests. Religious observance is encouraged. There is a good level of support from families and friends, and residents can choose who they see. EVIDENCE: Care records showed that each resident has a ‘life history’ drawn up, usually by family members. A ‘social assessment’ is also completed, and a social care plan is drawn up. These care plans need to be further developed to reflect the information gained from the assessments. The weekly social activities programme is displayed in the home, and the home’s activities diary showed that bingo, skittles and armchair exercises are popular. There is a designated part-time (25 hours) activities co-ordinator, who keeps a record of daily group and individual activities. There is a file with information on visiting entertainers and on community leisure opportunities. Sovereign Lodge Version 1.10 Page 13 The home’s statement of purpose and service users’ guide stress the commitment to maintaining the links with families and friends. The visitors book shows that there are frequent visitors to the home. The manager stated that every resident receives visitors, and many are taken out for trips by relatives. Residents may choose whether or not to see a particular visitor, and may see their visitors in private, if they so wish. Religious observance is recorded and supported, and there are monthly services held in the home. Sovereign Lodge Version 1.10 Page 14 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 standard(s) 16,17,18. Residents and their relatives seem confident that any complaints will be treated very seriously and addressed properly by the home. The manager takes pains to inform residents of their legal rights. There are appropriate systems for protecting residents from abuse, and evidence that staff will report any bad practice. EVIDENCE: The home’s complaints book was examined. There have been two complaints in the past year. One was about the level of support being received by a resident: this was partially sustained, and appropriate remedial actions were taken to resolve the problem. The second was an issue about hearing aid batteries: again, this was partly sustained, and remedial actions taken. Both complainants were said to be happy with the outcome of their complaint. The home has recently introduced new ‘comments and suggestions’ forms, to encourage feedback from residents and visitors. Eight out of ten relatives who filled in comments cards for this inspection said that they are aware of the home’s complaints procedures; three said that they had ever made a complaint. The home’s statement of purpose and service users guide both stress the home’s commitment to maintaining the legal rights of residents. The manager Sovereign Lodge Version 1.10 Page 15 was able to give examples of where she has informed residents of their legal rights, and especially their rights to benefits. All residents receive postal votes. Advocacy services are advertised in the home. Appropriate policies and procedures to safeguard residents from abuse were seen. These include a staff ‘whistle blowing’ policy. One allegation of abuse has been made in the past year. The home responded quickly and appropriately to this allegation, and it was fully investigated. The outcome was that the allegation was not upheld. Sovereign Lodge Version 1.10 Page 16 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 standard(s) 19,21,26. Residents live in a safe, comfortable and well-maintained home. There is generally sufficient toileting and bathing facilities, but there is a call from some relatives for more showering facilities. The home is kept very clean, and is warm, pleasant and hygienic. EVIDENCE: The home was toured. It was warm, clean, tidy and odour-free. Its layout is generally well suited for its stated purpose. The maintenance book was inspected. It was up to date and showed that repairs are dealt with promptly. The service file was inspected. It contains servicing documentation, contracts etc., and was up to date. Sovereign Lodge Version 1.10 Page 17 It was a recommendation of the last inspection that another shower facility is installed. This has been taken up with the company but no decision has been reached. This is still an issue, commented upon by one relative, and this recommendation is repeated in this report. Sovereign Lodge Version 1.10 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28. Residents’ needs are met by having sufficient numbers of staff on duty at all times. However, the home has yet to have achieve the necessary 50 of care staff with NVQ2 in care (although, with the number of staff currently being trained, it should meet this within a relatively short time). EVIDENCE: The home’s staff rotas were examined. The home is staffed at the agreed levels i.e. seven carers from 8am-2pm; six carers from 2pm-8pm; and one senior and three carers at night. Seven of the ten relatives who completed comments cards for this inspection felt that there were sufficient staff on duty; three did not. There is one vacancy, which is in the process of being filled. All carers are at least 18y.o. and no-one under the age of 21 is ever left in charge of the building. It was a recommendation of the last inspection that at least 50 of care staff should hold at least NVQ level two in care. This is still in the process of being implemented. Four care staff now hold this qualification, and a further nine should complete this in the next two months. Others are to start NVQ levels two and three. Sovereign Lodge Version 1.10 Page 19 Sovereign Lodge Version 1.10 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,35,38. The home is run by a very capable and competent manager, who is in the process of obtaining the required management qualification. Residents’ financial interests are protected by the home’s financial procedures. Health and safety issues are taken seriously, but there is a need for further staff training in this area. EVIDENCE: It was a recommendation of the last inspection report that the home’s manager, Mrs Audrey Alderson, should hold the Registered Manager Award by the end of 2005. This is in the process of being actioned. Positive comments were received from relatives as to the manager’s competence. All ten relatives Sovereign Lodge Version 1.10 Page 21 who completed comments cards for this inspection rated the overall care in the home as ‘good’. The home does not receive residents’ Personal Allowances directly, but will hold money at the request of the individual resident. The financial records of three residents were examined. These records were clear and up to date. There are two signatures for each entry. Money and valuables are securely stored, and all residents have a lockable facility in their bedrooms. No member of staff acts as an Agent for any resident. The home is well-maintained and equipment is regularly serviced. There are proper policies and procedures for safeguarding the health and safety of residents and staff. Not all staff have current accreditation in all areas of statutory training (eg health & safety and first aid. Such training must be completed for all staff within five months. All accidents and other significant incidents are reported to the CSCI. Sovereign Lodge Version 1.10 Page 22 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 x COMPLAINTS AND PROTECTION 3 x 2 x x x x 3 STAFFING Standard No Score 27 3 28 2 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 x x x 3 x x 2 Sovereign Lodge Version 1.10 Page 23 No Are there any outstanding requirements from the last inspection? 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 38 Regulation 18 (1) Requirement All staff should have current accredition in Health and Safety, First Aid (one qualified person per shift), Moving and Handling, Food Hygiene and Fire Safety Timescale for action 31.8.05 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. 2. Refer to Standard 21 28 Good Practice Recommendations In line with relatives request, residents would benefit from the installation of a second shower 50 of care staff to have obtained NVQ2 by 31.12.05 Sovereign Lodge Version 1.10 Page 24 Commission for Social Care Inspection Northumbria House Manor Walks Cramlington Northumberland National Enquiry Line: 0845 015 0120 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 Version 1.10 Page 25 - 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. 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