Inspection on 02/11/05 for Sovereign Lodge

This inspection was carried out on 2nd November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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.

Other inspections for this house

Sovereign Lodge 22/05/09

Sovereign Lodge 10/05/07

Sovereign Lodge 23/08/06

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 Alan Baxter Unannounced Inspection 09:30 2 , 11 & 22 November 2005 nd th nd 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.V255888.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. Sovereign Lodge DS0000000456.V255888.R01.S.doc Version 5.0 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 Ms Audrey Margaret Alderson Care Home 48 Category(ies) of Old age, not falling within any other category registration, with number (48) of places Sovereign Lodge DS0000000456.V255888.R01.S.doc Version 5.0 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. 12th April 2005 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. Sovereign Lodge DS0000000456.V255888.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over three days (the manager being on sick leave on the first day) in November 2005. Time was spent in the office, examining care records and other relevant documentation with, at different times, the manager, trainee deputy manager and area manager. The building was toured. Approximately twelve residents were engaged in conversation: all were very positive about their experiences living in the home, and all spoke highly of the manager and her staff. Some staff members were also asked their opinions: all were positive about the home. The inspection took ten hours in total. What the service does well: The home assesses all potential new residents very thoroughly and continues to re-assess every resident every month. The home takes all complaints very seriously, and acts properly in response to a complaint. The home provides a good, balanced diet, and tries hard to meet individual residents’ preferences. The home handles the administration of residents’ medicines in a professional way. The home is clean, hygienic, safe, warm, and free from offensive odours. The home has exceeded the target of having at least 50 of its care staff trained to NVQ level two in care, and has other staff ready to start such training. The home meets the requirement for all new staff to receive induction and foundation training at nationally required levels. The home takes its’ responsibilities for the safe recruitment of new staff seriously, and requires proper references, proof of identity, disclosure of any previous offences, and a detailed work history before employing any new staff. Sovereign Lodge DS0000000456.V255888.R01.S.doc Version 5.0 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. Sovereign Lodge DS0000000456.V255888.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 Sovereign Lodge DS0000000456.V255888.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): 3,6. 3) No resident moves into the home before his or her needs are properly assessed. 6) This standard does not apply to Sovereign Lodge, as it does not provide Intermediate Care. EVIDENCE: 3) The home requests, and receives, full written assessments of needs of all persons funded by the local authority before ageing to admit the person. In addition, the manager conducts her own assessment of needs before admission, to make sure that the home can fully meet those needs. This takes the form of a relatively brief ‘Activities of Daily Living’ assessment. This is supplemented by a more detailed assessment, post admission, as well as a range of other appropriate assessments, including social, psychological, nutritional, skin care, spiritual, and handling risk assessments. 6) (See judgements, above.) Sovereign Lodge DS0000000456.V255888.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): 7,9. 7) The home could demonstrate that it is in the process of meeting all the assessed needs of its residents. 9) Residents are protected by the home’s policies and practices for dealing with medicines. EVIDENCE: 7) Examination of assessments and related care plans showed that the home was meeting most, but not all, of the assessed needs of those residents sampled. However, the home was able to demonstrate that it was aware of the deficits and was in the process of reviewing all care plans, with the aim of making them more detailed and specific. In particular, residents’ social care plans are being more individualised, to reflect the wishes of each resident, as recorded in their social assessments. 9) The home’s policies, procedures and records of the receipt, storage, administration and returns of residents’ medicines had recently been subject to an audit by an N.H.S. Primary Care Trust Pharmacist. The Pharmacist’s report was inspected. No areas of concern had been identified, and no recommendations for improvement had been made. Sovereign Lodge DS0000000456.V255888.R01.S.doc Version 5.0 Page 10 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): 12,14,15. 12) Residents’ social, religious and recreational interests are generally well addressed, and there is a good activities programme available to them. 14) Residents are encouraged to exercise choice and control over their lives. 15) Residents receive a good balanced diet, which includes a good degree of choice. EVIDENCE: 12) The home has recently employed a full-time activity co-ordinator, Julie Costigen, who was pleased to discuss her role in the home. She was very enthusiastic that, after a few months where residents seemed unwilling to get involved in activities, they are now becoming much more enthusiastic and involved. The co-ordinator spends her mornings mostly in one-to one sessions with individual residents, getting to know them and their preferences, and escorting them to local shops etc. Afternoon activities are focussed on the ‘Chattery’, the home’s coffee shop, which seems to be the hub of the home. Sovereign Lodge DS0000000456.V255888.R01.S.doc Version 5.0 Page 11 Activities include cards, dominos, singalongs, carpet bowls, bingo, quizzes, and painting. The home also celebrates festivals such as Christmas, Easter, Burns’ night, Mayday, Halloween, and has spring and summer fairs. There are visiting entertainers about every six weeks. As noted in standard 7), above, the home is attempting to develop a more individualised approach to the provision of social activities, to get away from the ‘everyone down for bingo’ approach. This is good practice and is strongly encouraged. 14) Where possible, residents are encouraged and supported to handle their own affairs. This is only possible for a small number of residents, currently, and other residents receive help from their families. Advocacy services are advertised in the home, as is a contact for financial advice. Officers from the Department of Work and Pensions have visited the home to check that all residents are receiving all their full state benefits. Residents frequently bring their own possessions into the home when they are admitted. Records are kept in accordance with the Data Protection act. 15) The home’s menus were examined. They cover a recurring four-week period. They appeared to be well balanced and nutritious, and to have a good degree of choice. Discussion with the cook, and inspection of the records kept of residents’ menu choices, showed that every effort is made to accommodate individual residents’ particular choices, even if these are not on the menu. This is good practice. The daily vegetables served are not currently shown on the menu. It was agreed that this would be rectified immediately, and copies of the revised menus sent to the Commission. Sovereign Lodge DS0000000456.V255888.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): 16,18. 16) Complaints are listened to, taken seriously and acted upon. 18) Residents are protected from abuse, but further staff training is required in this important area. EVIDENCE: 16) An anonymous complaint was received by the CSCI in October this year. There were a number of elements of the complaint, which the company was asked by the CSCI to investigate. The first was that, due to low staffing levels, day staff were also covering nights, and were sleeping on duty. This was sustained, and was found to have been at the instruction of line management. The company accepts that such practices are not acceptable, and a requirement to this effect is made in this report. It is also recommended that the home keep a log for recording all contacts with the staff agencies it occasionally uses. The second was that maintenance in the home is poor (not sustained), and that a bath was out of action for a long period (sustained). The third allegation, that the home did not provide suitable lifting equipment for a named resident, was partially sustained, in that although immediate action was taken by the company when it was reported to them, the resident’s need for such equipment had been identified within the home some weeks previously, and not acted upon. Sovereign Lodge DS0000000456.V255888.R01.S.doc Version 5.0 Page 13 The fourth allegation, that the general hygiene in the home was poor, was not sustained. Finally, it was alleged that there was high staff turn over. This was found to be partially sustained, but to have since been rectified. 18) The home has appropriate policies in place for the recognition and prevention of abuse of residents. Study of staff training records and discussion with management, however, showed that staff currently receive only a brief video presentation on abuse. More detailed training is required for care staff, and a requirement is made to that effect. Sovereign Lodge DS0000000456.V255888.R01.S.doc Version 5.0 Page 14 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): 19,26. 19) Residents live in a safe, and generally well-maintained environment, although a bath was recently out of action for an unacceptable length of time. 26) The home is clean, pleasant and hygienic. EVIDENCE: 19) The building was toured. No obvious safety issues were discovered. The service records showed that appropriate contracts for the servicing of all equipment are in place, and that such servicing takes place at the agreed regularity. The in-house maintenance log had detailed daily entries, demonstrating that maintenance issues are picked up and followed through by the home’s handyman. Sovereign Lodge DS0000000456.V255888.R01.S.doc Version 5.0 Page 15 However, the recording and tracking of repairs that required the service of outside contractors were much less clear, and should be formalised. As an example, a complaint received in October identified that a bath had been out of commission for a significant length of time, waiting for parts, but there was insufficient documentary evidence in the service file that the home had actively chased up the required repairs. 26) The home was found to be clean, pleasant and hygienic. Sovereign Lodge DS0000000456.V255888.R01.S.doc Version 5.0 Page 16 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): 27,28,29,30. 27) At the time of this inspection, the numbers of staff in the home was appropriate; however, staffing levels at night were not fully maintained in the previous month, due to staff turnover. 28) The home has exceeded the percentage of staff required to hold National Vocational Qualification (NVQ) level two in care. 29) The home’s recruitment and selection processes are thorough, and should keep residents safe. 30) Staff are generally trained and competent to do their jobs; but there are gaps in statutory/mandatory training, in adult protection training; and in inhouse fire instruction. EVIDENCE: 27) An anonymous complaint regarding staff shortages and night staff sleeping on duty was received by the CSCI in October this year. This complaint was passed on to the company to investigate. The outcome of the company’s investigation was that staff shortages had lead the home’s staff being asked to work double shifts (day and night) for a number of weeks. Such staff were given managerial position to get some sleep during the night shift, if it was quiet. The company accepts now that this was an inappropriate instruction to staff; that agency staff should have been called upon; and the CSCI informed of any staffing problem. A requirement is made to that effect in this report. Sovereign Lodge DS0000000456.V255888.R01.S.doc Version 5.0 Page 17 At the time of this inspection, the home had recruited new staff, and was running at the agreed staffing levels. 28) It was a recommendation of the last inspection report that at least 50 of care staff to have obtained NVQ2 by 31.12.05. Study of staff training records showed that this target has been met, and, indeed, exceeded. Eleven care staff now hold NVQ level two in care, and three others hold NVQ level three. Also, another eight members of staff are ready to start this qualification. Trainee staff are registered on TOPSS induction courses. 29) A number of staff personnel files were examined. They were found to contain two written references; completed job application forms; interview minutes and statements of terms and conditions. However, in line with company policy, the home does not keep Criminal Record Bureau (CRB) records on the premises. These are held at head office for security and confidentiality reasons. It has been agreed that such records would be made available to the inspector on the day of any inspection. This was tested on a follow up visit, and the company was able to deliver the required CRB documents for inspection, give some hours notice. These records were found to be in good order, and to meet this standard. It was advised that the home’s manager keeps copies of the identification documents produced by new staff which are currently also sent to head office. 30) Staff training records demonstrated that all new staff receive National Training Organisation induction training, starting within six weeks of employment; and foundation training within the first six months of employment. Not all staff were found to be up to date with the required statutory training (see standard 38, below). Staff are also not being given the required level of training in the protection of vulnerable adults (see standard 18, above); nor are they being given the required in-house fire safety training (see standard 38, below). Sovereign Lodge DS0000000456.V255888.R01.S.doc Version 5.0 Page 18 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): 31,33,38. 31) The home’s manager is experienced, RGN-qualified, of good character, and well able to fully discharge her responsibilities for the home. 33) The home is run in the best interests of the residents. 38) The health and safety of the residents and staff are promoted and are generally well protected, but not all staff are up to date with all areas of training required by statute; and in-house fire training needs to be extended. EVIDENCE: 31) The home’s manager, Ms Audrey Alderson, holds the RGN qualification, as well as D32/33 qualification. She is currently working towards achieving the Registered Manager Award and NVQ level four in management. A change of course assessor has delayed her achieving these qualifications, but she anticipates that she will complete by the end of March 2006, and will then fully meet this standard. Sovereign Lodge DS0000000456.V255888.R01.S.doc Version 5.0 Page 19 33) Residents confirmed that they are well cared for, and have trust and confidence in the manager and her staff, who are described as being kind and caring. They said that they are treated with respect and that staff listen to them and will act on any concerns. 38) It was a requirement of the last inspection report that 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. This has been only partly implemented, and this requirement is repeated in this report. Study of staff training records showed that, although there is a ‘rolling programme’ of such training, not all staff are currently up to date in all the required areas of training. Study of the home’s fire log book showed that, although the home provides staff with annual external fire safety training and carries out regular fire drills, it does not provide staff with the necessary in-house fire instructions, as required by Tyne & Wear Fire Brigade. These must take place every three months for night staff, and every six months for day staff, and a requirement is made to this effect in this report. Sovereign Lodge DS0000000456.V255888.R01.S.doc Version 5.0 Page 20 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 4 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X X X X 2 Sovereign Lodge DS0000000456.V255888.R01.S.doc Version 5.0 Page 21 YES 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 OP38 Regulation 18(1) Requirement All care staff should have current accreditation in Health and Safety, First Aid (one qualified person per shift), Moving and Handling, Food Hygiene and Fire Safety. All care staff must be given inhouse fire safety instruction at the required frequencies (night staff, every three months; day staff, every six months). The home must be staffed at the agreed levels at all times. Clear records must be kept of all requests made to employment agencies for temporary staff. The CSCI must be kept informed of any staffing deficits. All staff must be given appropriate training in the ‘Protection of vulnerable Adults’ (POVA). Timescale for action 31/12/05 2 OP27 18(1) 30/11/05 3 OP18 13(6) 31/03/06 Sovereign Lodge DS0000000456.V255888.R01.S.doc Version 5.0 Page 22 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 31.1 19.2 Good Practice Recommendations The manager should hold the Registered Manager Award by 31.03.06. Clear records should be kept of all requests to outside companies for repairs and maintenance issues. Sovereign Lodge DS0000000456.V255888.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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. 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