CARE HOMES FOR OLDER PEOPLE
Sovereign Lodge Newbiggin Lane Westerhope Newcastle Upon Tyne Tyne & Wear NE5 1NA Lead Inspector
Mary Blake Key Unannounced Inspection 22nd and 23rd August 2006 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 Sovereign Lodge DS0000000456.V295966.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.V295966.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 Vacant Care Home 48 Category(ies) of Old age, not falling within any other category registration, with number (48) of places Sovereign Lodge DS0000000456.V295966.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. 2nd November 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. The current fees are £355 to £425 per week. Sovereign Lodge DS0000000456.V295966.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. Fourteen residents and seven staff (carers and ancillary) were spoken to. Others were chatted to briefly. Three relatives were spoken to during the visits. Nine resident and two relative questionnaires were received. 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. 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 staff have a good understanding of residents individual needs. The residents and relatives were very complimentary about the staff. For example “the staff are very kind” “staff are very helpful” “all the staff do a good job” “ I am very happy here and the staff are very good to me”. Staff recruitment records were clear and concise and contained all relevant information. The vetting process helps protect residents. The domestic and laundry staff provides an efficient and organised service giving residents a clean and pleasant home and well laundered clothes. The home has strong links with supporting health professionals, which will give good health support to residents. The home is very clean, well decorated and furnished to a good standard. “ It always looks sparkling clean”. Sovereign Lodge DS0000000456.V295966.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better:
Residents and their families could be more involved with their care plan to ensure that it meets their needs. Medication systems and staff awareness must be reviewed to ensure that all medications are safely accounted for. The quality and presentation of the meals, the choices to residents and the organisation of the dining arrangements must be improved so that residents can enjoy good food in pleasant surroundings. Menus must be followed and all catering staff must obtain their food hygiene training this will ensure that residents receive a varied and balanced diet that is safely prepared and served. Comments from residents included “the meals, especially lunch are not always up to standard” “there is not much variety” “ Sunday lunches are not very hot and the vegetables are overcooked” “I have complained about the food on several occasions but there had been no improvement” All staff in the home must be made aware of POVA and Whistle blowing procedures and have received appropriate training, as this may compromise residents safety. A staff training programme must be available; this must include dates of completion for mandatory, NVQ and other training, this will confirm that the staff team have the skills and training to meet the needs of residents. Staff must be supervised within the recommended timescales of six times per year as this provides the management overview of staffs ability to provide satisfactory care for residents. Consistency with management and staff must be addressed to give reassurance to residents. Sovereign Lodge DS0000000456.V295966.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. Sovereign Lodge DS0000000456.V295966.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.V295966.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,4 & 5 6 Sovereign Lodge does not provide intermediate care. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the 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 acting 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.V295966.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 he was able to visit and meet staff and the felt he and his family were involved throughout. They felt that this helps new residents adjust and settle into living in the home. Sovereign Lodge DS0000000456.V295966.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 at least once during a 12 month period. 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 from evidence gathered both during and before the visit to this service The health and social care needs of residents are being met but the involvement of the residents and their family/supporter must improve. Residents are generally protected by the homes policies and procedures for dealing with medicines, but records must improve. Residents feel they are treated with respect and their right to privacy is upheld. EVIDENCE: Four care plans were examined. The assessment tools such as pressure care, nutrition, moving and handling, mental health and dependency are completed
Sovereign Lodge DS0000000456.V295966.R01.S.doc Version 5.2 Page 12 consistently. Periodic evaluations are consistent. There is minimal involvement of residents and their families. Contact with social and health professionals is good and there were a number of professional visitors throughout the day including GP and District Nurse. The new manager and the Company have already 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 generally well managed and safely disposed. The treatment room was tidy. The controlled drugs were audited and were unsatisfactory with additional stock according to the records. Visitors and residents feel that they are treated well and their privacy is respected. Sovereign Lodge DS0000000456.V295966.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13, 14, & 15 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the 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 do not receive a wholesome, appealing; balanced diet and dining arrangements were chaotic. EVIDENCE: The home has a new 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, “we are informed of all activities and the choice is up to each of us whether or not to take part”
Sovereign Lodge DS0000000456.V295966.R01.S.doc Version 5.2 Page 14 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. They did share concerns about the unsettled management arrangements and staffing changes, “ high staff turnover, at all levels, six managers in less than five years”. 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 no evidence of residents or relatives involvement 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. 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 lack of trips “the homes in its leaflets promises trips out but these do not seem to occur” “ it would be good if the Home could arrange trips out as their brochure promises”. The residents’ bedrooms were personalised reflecting individual choices and preferences. 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. The home does not have the menu displayed visibly although the display board at the entrance details the meals for the day. The menu was not being followed. Residents are asked for their choice for lunch and tea daily, which is recorded and given to the kitchen staff. The food being served on the first visit was poorly presented, cold and not properly cooked. A number of residents expressed their dissatisfaction with the dining arrangements, that the quality of the food served is often poor, that long waits are normal and that they have raised their concerns about the repetitiveness of the food. The residents sat and waited over 1 hour and 10 minutes before their food arrived with residents sitting at the same table being served at different times, they expressed their concerns “it doesn’t feel right to start when we haven’t all got” “we always wait like this” “the food is often cold” Several staff served the food and drinks to residents without any acknowledgement of their needs. From one table all three residents did not have their needs met, one resident specifically doesn’t have gravy, this is detailed within her care plan, but was served her meal with gravy, one resident asked for a small portion and was served a very large portion “this puts me off my food” “I don’t feel like eating
Sovereign Lodge DS0000000456.V295966.R01.S.doc Version 5.2 Page 15 this now”, the last resident did not receive a pudding until he asked and the table was being cleared. Other residents, and questionnaires, stated that this often happens. Tea was served with milk already in cups with little choice for residents on how they like their tea. On the second visit the dining room was better organised, with minimal waiting, the food was better quality, this suggests that there is inconsistency in a number of practices in the home. The acting Registered Manager was unaware of these inconsistencies but will take step to address them. Sovereign Lodge DS0000000456.V295966.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the 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 but all staff must be trained. 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. The home has a Protection of Vulnerable Adults (POVA) procedure, which complies with the Department of Health ‘No Secrets’ Guidance. Not all of the staff in the home have received POVA training this may compromise residents safety. Sovereign Lodge DS0000000456.V295966.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the 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. 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.
Sovereign Lodge DS0000000456.V295966.R01.S.doc Version 5.2 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 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 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the 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 day 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 high turnover of staff in the past year residents and relatives comments, “Why do the carers disappear?” “I just manage to remember their names then they don’t appear again”, the acting Registered Manager and Area Representative are confident that this will now be addressed. Good ancillary support was in place. Four staff recruitment files, across all grades, were inspected and were satisfactory. Training files examined did not clearly detail what training staff had completed for induction, foundation, mandatory and NVQ training. The acting Registered
Sovereign Lodge DS0000000456.V295966.R01.S.doc Version 5.2 Page 19 Manager had begun to address the shortfalls in mandatory training with session being held in June and July. The inspector was unable to clarify who had obtained NVQ level 2, this information was subsequently submitted and confirms that more than 50 of staff has completed this training. Sovereign Lodge DS0000000456.V295966.R01.S.doc Version 5.2 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 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): 31,33,35,36,37 & 38 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the 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. Resident’s financial interests are safeguarded. Staff are not always appropriately supervised. The health, safety and welfare of residents and staff are generally protected. EVIDENCE: Sovereign Lodge has a new manager, Marion Redhead, who is about to submit her application to become registered for this home. Mrs Redhead has previous experience as a Registered Manager within the company, is qualified to level 4
Sovereign Lodge DS0000000456.V295966.R01.S.doc Version 5.2 Page 21 NVQ and is in the process of completing her Registered Managers Award. Mrs Redhead is only responsible for Sovereign Lodge. Good quality assurance arrangements are in place. 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. The Company have corresponded with families during the uncertain management period. The Administration Manager, Pharmacist and Property management, periodically undertake quality audits. The Operations Manager is reviewing policy and procedures. Resident monies records were checked; there was evidence of regular personal expenditures, with two staff signatories for all transactions. Money balances were checked and found to be correct. Receipts were available. Staff supervision on a 1:1 basis has not occurred due to the management situation. The new manager now intends to reintroduce this with staff. 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. Sovereign Lodge DS0000000456.V295966.R01.S.doc Version 5.2 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. 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 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 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 3 X 3 X 3 2 2 3 Sovereign Lodge DS0000000456.V295966.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP38 Regulation 18(1) Requirement The Registered Person must ensure that all care staff have current accreditation in Health and Safety, First Aid (one qualified person per shift), Moving and Handling, Food Hygiene and Fire Safety. Outstanding as of 31st December 2005 but good progress being made Timescale for action 31/12/06 2. OP18 13(6) 3 OP7 15(2)(c) The Registered Person must ensure that all care staff must be given in-house fire safety instruction at the required frequencies (night staff, every three months; day staff, every six months). Outstanding as of 31st December 2005 but good progress being made. The Registered Person must 31/10/06 ensure that all staff must be given appropriate training in the ‘Protection of vulnerable Adults’ (POVA). Outstanding as of 31st March 2006 The Registered Manager must 31/12/06 ensure that residents and their
DS0000000456.V295966.R01.S.doc Version 5.2 Page 24 Sovereign Lodge 4 OP9 13(2) 5 OP15 16 (2) (i) 6 OP27 18(1) 7 OP36 17(2) 18(2) Schedule 4 families/supporters are fully involved with their care plan The Registered Manager must ensure that controlled drugs are safely stored and accounted for within the home. This has now been met The Registered Manager must review the quality of the meals, choices to residents and the organisation of the dining arrangements. The Registered Person must ensure that all catering staff completes basic food hygiene and intermediate food hygiene as necessary. Date 11th September 2006 has subsequently been organised. The Registered Manager must ensure that all staff receives supervision at least six times per year. 15/09/06 01/10/06 01/12/06 31/12/06 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.V295966.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: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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