Inspection on 20/09/06 for St Aidan Lodge

This inspection was carried out on 20th September 2006.

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

St Aidan Lodge 12/09/07

St Aidan Lodge 07/11/05

St Aidan Lodge 08/06/05

St Aidan Lodge 16/02/05

St Aidan Lodge 27/05/04

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 St Aidan Lodge St Aidan Lodge Front Street Framwellgate Moor Durham DH1 5EJ Lead Inspector Bridgit Stockton Unannounced Inspection 20th September 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 St Aidan Lodge DS0000007502.V303907.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. St Aidan Lodge DS0000007502.V303907.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Aidan Lodge Address St Aidan Lodge Front Street Framwellgate Moor Durham DH1 5EJ 0191 3709691 0191 3865806 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) Ideal Care (North) Limited Ms Carol Ann Shannon Care Home 62 Category(ies) of Dementia - over 65 years of age (32), Old age, registration, with number not falling within any other category (30) of places St Aidan Lodge DS0000007502.V303907.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 30 Older Persons and 32 Older Persons with Dementia Date of last inspection 7th November 2005 Brief Description of the Service: St Aidan Lodge is a purpose built care home situated in the centre of Framwellgate Moor, on the outskirts of Durham City. It caters for 62 residential service users on two floors, with the kitchen, laundry and additional facilities located in a basement area. St Aidan Lodge is registered to provide personal care for 30 older people situated on the ground floor, and 32 older people with dementia situated on the first floor. The home is spacious, with a variety of communal space, including lounge and dining areas, a smoking room and spacious garden area. All bedrooms are large single rooms with en-suite toilet and washing facilities. Rooms are well equipped and furnished and there are a number of suitably equipped and adapted bath and shower rooms. The range of fees charged at the home are £364.50 to £417.00 per week. St Aidan Lodge DS0000007502.V303907.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over a period of 6 hours on the 27th September 2006. The home did not know the inspection was going to take place. The plan for the inspection was to check whether the home had implemented the requirements and recommendations made at the previous inspection; to talk with the residents about living in the home; to meet with care staff and the home’s management team; and to look at records. A pre inspection questionnaire had also been returned to the Commission. Some of this information has been included within this report along with some service users comments about the service. What the service does well: What has improved since the last inspection? All service users care plans have been reviewed and the way in which peoples care is recorded has now improved so staff are clear on what assistance service user need to ensure they are getting the right care and support. Since the last inspection the way in which service users medication is managed has improved, and a clear audit trail is now in place. Refurbishment and redecoration has taken place and the home is very well maintained. A deputy manager has been appointed to the home as well as an activities coordinator. St Aidan Lodge DS0000007502.V303907.R01.S.doc Version 5.2 Page 6 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. St Aidan Lodge DS0000007502.V303907.R01.S.doc Version 5.2 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 St Aidan Lodge DS0000007502.V303907.R01.S.doc Version 5.2 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): 2,3,&6 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Prospective service users can be assured that their needs are appropriately assessed prior to admission to the home and that they are given sufficient information to make an informed choice before moving into the home. EVIDENCE: The home’s Statement of Purpose and Service User Guide have been updated. These guides contain all of the information that is required to enable people to make an informed choice about where to live. Evidence was seen that service users or their representatives have signed a contract with the home. The contracts were detailed and included a breakdown of the fees and who was responsible for paying them. The manager confirmed that she always visits prospective service users before their admission to the home, to carry out an assessment of needs. Four service users files inspected had pre admission assessments and care management assessments so that a decision could be made about whether the home was suitable and able to meet the needs of the individual. Intermediate care is not provided at St Aidans St Aidan Lodge DS0000007502.V303907.R01.S.doc Version 5.2 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): 7,8,9,10 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Good systems are in place to ensure that health care needs of the service users are met. Service users can be confident that they are treated with respect. EVIDENCE: Since the last inspection a robust service user plan has been developed for each service user that identifies needs associated with health and personal care. This ensures that staff are clear about what is required of them in meeting service user’s needs. The care plans of four residents were inspected, they were comprehensive and well written. Careful and thoughtful strategies to address particular needs or problems of some service users were well documented and sensitively written. Some care plans did not contain risk assessments regarding service users smoking this requires review. There was evidence of involvement of specialist healthcare people such as the community psychiatric nurse, the dietician and continence nurse. The management and administration of medication is carried out appropriately and audited by the manager on a regular basis. Medication administration records were inspected and completed properly. The residents spoken to felt St Aidan Lodge DS0000007502.V303907.R01.S.doc Version 5.2 Page 10 that the staff “were wonderful” and that their particular needs and wishes were addressed in a kind and professional manner. Residents confirmed that their privacy is maintained and respected by staff. One service user said, “ the staff here are tremendous, I know I am going to be looked after, I always get a cup of tea when I need one, just at the right time” St Aidan Lodge DS0000007502.V303907.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,15 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 recreational and social needs of service users are well catered for which enables service users to make daily choices and promotes independence. EVIDENCE: The home employs an activities co-ordinator who produces a varied and interesting activities program, appropriate to service users’ needs and interest. Activities range from trips out to the theatre and shopping to arranging in house entertainers and craft demonstrators. There are also sessions on baking and knitting to encourage service users to maintain their independence skills, and quizzes to stimulate the memory. Service users were seen having lunch and appeared to be enjoying the food served. One service user confirmed, “I am always asked what I would like for lunch”. Another said, “I would give first prize to the food it’s just like I would cook at home” Visitors are welcomed at the home at anytime. One service user commented, “I see my family a lot. It’s great they come and go and the staff are really friendly and make them feel welcome” St Aidan Lodge DS0000007502.V303907.R01.S.doc Version 5.2 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 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. People can be assured complaints would be investigated and outcomes recorded. Staff were aware of measures to take in case of abuse of a vulnerable adult. EVIDENCE: There are adequate written policies and procedures in place to deal with complaints and the care staff spoken to confirmed they were aware of these. Written records of complaints and the outcomes are kept at the home. Service users said they would complain to the manager if they were at all unhappy. Staff training has taken place in the protection of vulnerable adults in abuse. Staff recruitment procedures were adequate and staff were employed and deployed following appropriate CRB and POVA checks. The manager and staff team were clear and confident in the protection of vulnerable adult procedures. St Aidan Lodge DS0000007502.V303907.R01.S.doc Version 5.2 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home was clean, comfortable and well-maintained providing service users with a safe and pleasant environment EVIDENCE: Individual bedrooms and communal areas were suitably furnished and decorated in a style liked by people living there. The entrance foyer has been refurbished and service users bedrooms redecorated. Several communal areas have also been re-carpeted. Residents spoken to said they liked being able to bring into the home small items of furniture along with pictures and photographs to make there own rooms more pleasant and feel more like home. The communal areas of the home were clean and residents confirmed that their bedrooms were also cleaned to a good standard. St Aidan Lodge DS0000007502.V303907.R01.S.doc Version 5.2 Page 14 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 adequate. This judgement has been made from evidence gathered both during and before the visit to this service. In some instances there is not enough staff on duty to meet service users needs. The recruitment and training of staff is good which contributes to the ongoing safety of service users. EVIDENCE: At the time of the inspection the staffing levels during the daytime seemed reasonable and the manager said that she was normally around to help if staff were busy. Staff are deployed within the two units of the home. These units are set over two floors. It was of concern, that from 20.00hrs until 08.00hrs on some occasions there were only 3 members of night staff deployed throughout the home. Given the dependency of service users, particularly in the dementia unit and the layout of the building, it is the inspector’s view that there was not enough staff on duty during this time to ensure that service users needs could be met safely. Following the inspection where there was a deficit in staffing levels the manager has increased the amount of staff on duty to an appropriate level. It is the manager’s responsibility to monitor this to ensure that staff are deployed in sufficient numbers in a twenty four hour period to meet the needs of the client group. Although staff had adequate induction and training, some practices did not look after people’s dignity to good enough standard this was with regard to St Aidan Lodge DS0000007502.V303907.R01.S.doc Version 5.2 Page 15 assisting some service users on the dementia care unit in the morning carrying out personal care. For example two sets of dentures where found in a service users bedroom. One set belonged to the service user who’s bedroom it was, the other to another service user. Both sets were dirty and needed a thorough clean. It is hoped this can be improved by change of practice, proper staffing levels and by close supervision of staff. 75 of care staff have completed the NVQ2 qualification in direct care. Training has taken place in safe administration of medication, moving and handling, first aid, risk assessment and dementia care awareness. The home had staff files in place that provided evidence that the appointment of a new staff member is made through proper recruitment processes. This includes the vetting of staff through the use of references, POVA first checks and Criminal Record Bureau (CRB) checks. St Aidan Lodge DS0000007502.V303907.R01.S.doc Version 5.2 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users can be confident that the home is well managed. Systems and safeguards are in place to ensure the health, safety and welfare of service users and staff is protected. EVIDENCE: The manager of the home is experienced in managing a care service. There was an open, friendly culture between the management team and the staff at the home, and staff said they felt very well supported in their work. Service users said that the manager was very approachable and they would go to her or any of the staff if they had any concerns. Regular service users meetings take place that and minutes where available for inspection. Action is taken following any issues raised during these meeting. A service satisfaction St Aidan Lodge DS0000007502.V303907.R01.S.doc Version 5.2 Page 17 questionnaire is also used within the home, some of these are sent to the Commission as part of the monthly registered providers report, all of these questionnaires have been very positive about the service. The records regarding administration of residents’ personal allowances were inspected. All transactions are recorded correctly and receipts are kept. The homes health and safety file was examined; all equipment in the home is regularly checked with valid certificates issued. There are no outstanding issues from environmental health inspections or the fire and rescue services. St Aidan Lodge DS0000007502.V303907.R01.S.doc Version 5.2 Page 18 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 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 3 X X X X X X 3 STAFFING Standard No Score 27 1 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 St Aidan Lodge DS0000007502.V303907.R01.S.doc Version 5.2 Page 19 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. 1 Standard OP10 Regulation 13 Requirement The manager must ensure that all service users are treated with dignity especially when personal care is delivered Staff must employed and deployed in sufficient numbers in order to meet service users needs Timescale for action 27/09/06 2 OP27 18 27/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations It is recommended that risk assessments on service users who smoke at the home are reviewed. St Aidan Lodge DS0000007502.V303907.R01.S.doc Version 5.2 Page 20 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS 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 St Aidan Lodge DS0000007502.V303907.R01.S.doc Version 5.2 Page 21 - 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. 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