This inspection was carried out on 15th January 2010.
It is an annual review prepared by CQC after examining previous reports and information from the provider. At the time of this report, CQC judged the service to be Good.
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.
Annual service review
Name of Service: St Andrews Lodge Care Home The quality rating for this care home is: The rating was made on: two star good service 0 4 1 1 2 0 0 8 A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection We do an annual service review when there has been no key inspection of the service in the last 12 months. It does not involve a visit to the service but is a summary of new information given to us, or collected by us, since the last key inspection or annual service review.
Has this annual service review changed our opinion of the service?
No You should read the last key inspection report for this service to get a full picture of how well outcomes for the people using the service are being met. The date by which we will do a key inspection: Name of inspector: Angela Starr Date of this annual service review: 1 4 1 2 2 0 0 9 Annual Service Review Page 1 of 6 Information about the service
Address of service: Riber Crescent Basford Nottingham NG5 1LP 01159245467 01159245485 slodge@schealthcare.co.uk www.southerncrosshealthcare.co.uk Trinity Care Limited Telephone number: Fax number: Email address: Provider web address:
Name of registered provider(s): Name of registered manager (if applicable) Mr Karsten Klups Conditions of registration: Category(ies) : dementia mental disorder, excluding learning disability or dementia Conditions of registration: Number of places (if applicable): Under 65 Over 65 0 0 80 80 No person falling under category MD(E) Mental Disorder older people over 65 years (excluding Learning Disability or Dementia) or DE(E) Dementia shall be admitted to St Andrews Lodge when there are already 80 persons of these categories/combined categories accommodated in the home The maximum number of persons to be accommodated within St Andrews Lodge is 80 To admit into St Andrews Lodge 10 service users aged between 50 - 65 years under category DE To admit into St Andrews Lodge one named service user aged 40 years under category DE To admit into St Andrews Lodge one named service user aged 45 years under category DE Have there been any changes in the ownership, management or the Yes service’s registration details in the last 12 months? If yes, what have they been: The service had a new registered manager, Karsten Klups but he has now left and there is currently no registered manager in post.
Page 2 of 6 Annual Service Review However, there is an acting manager who is in post until the newly recruited manager is able to take up his position. Date of last key inspection: Date of last annual service review (if applicable): Brief description of the service St. Andrews Lodge provides nursing care for 72 older people with Mental Illness and for those with Dementia. The registration allows for up to 10 people between the ages of 50- 65yrs to be accommodated. The purpose built home is split into two separate nursing units, Garden and Assisi, and a residential care unit, Robin. There are lounge and dining areas in each of the units which are comfortable and suitably furnished to cater for the people living there. There is a hairdressing salon in the home and the hairdresser visits twice a week. Sited in an established residential area the home has sufficient car parking and a well maintained garden. All areas of the home were accessible to service users. The fee range is from £356.00 to £807.00 per week including the nurse determination fee. One to one support can be provided where there is an assessed need but this does incur further costs and is currently £1.071.27 per week. The Registration Certificate is prominently displayed in the entrance area of the home, together with copies of the Service User Guide, Statement of Purpose, the complaints procedure and daily menus. A copy of the last Key Inspection that took place on the 4th November 2008, can also be found in the entrance of the home and on the web site for the Care Quality Commission. 0 4 1 1 2 0 0 8 Annual Service Review Page 3 of 6 Service update since the last key inspection or annual service review:
What did we do for this annual service review? We looked at all the information that we have received or asked for, since the last key inspection or annual service review. This included, The annual quality assurance assessment (AQAA) that was sent to us by the service. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. Information we have about how the service has managed any complaints. What the service has told us about things that have happened in the service. These are called notifications and are a legal requirement. The previous key inspection. Relevant information from other organisations. What other people have told us about the service. A telephone conversation with the Registered Manager for the service on 02/10/2009. What has this told us about the service? We received the Annual Quality Assurance Assessment from the manager when we asked for it. It was completed in a very thorough manner and provided us with a lot of useful and up to date information. The AQAA told us Our service provides quality care for all of the service users that are present within the home. We listen to people and take action if required from any comments that are made to us regarding the home. The environment is one of calm and this reflects well upon the people that we care for. We also received seven completed questionnaires from people living at the service and three from members of staff. We asked people Do you know how to make a formal complaint? All seven replied No but where we asked if people had someone to speak to informally if they were unhappy, all replied Yes. The Annual Quality Assurance Assessment tells us We have the complaints procedure on view in the reception area and it also contains information on how to word and go about making a complaint, it is also included in the service user guide which all Service Users and relatives receive when coming in to the home. This indicates that people may require on-going support from staff to enable them to remember and use the procedures for dealing with their complaints. The AQAA also tells us Service Users who lack capacity have the right to advocacy. Information of advocates is displayed in the main reception. This information needs to Annual Service Review Page 4 of 6 be conveyed to the people who need it in a manner which enables them to understand and use the services offered. A number of comments included in the completed questionnaires refer to staff numbers not being adequate to enable staff to spend time with people. However, there are also a number of positive comments regarding the standard of care and support provided for people. I am well looked after so they are doing a good job as far as I am concerned. Staff are kind and work hard. The questionnaires completed by staff tell us that they receive a good level of training to enable them to do their job and they feel supported by the manager. The manager referred to in these questionnaires has left the service and will be replaced by a newly appointed manager in the very near future. There is an acting manager at the service in the interim period. We know that situations have occurred that have put people at risk and these have been reported to the Local Authority Safeguarding Adults Team and have been managed in the right way, following the policies and procedures around Safeguarding Adults. (Safeguarding Adults is a process of identifying and reporting suspected or potential abuse of vulnerable people and provides a framework of consistency to protect those individuals at risk.) The manager has been quick to report these occurrences to us and to seek resolution. We telephoned the manager and discussed any issues that have occurred. We are aware of a number of incidents that require reporting under regulation 37 (This is a regulatory process which informs us of any reportable incidents that occur at a service and is a legal requirement.) We were satisfied that these had been dealt with in line with policy and procedure. The last inspection report shows that at the time of our visit, people were receiving good quality outcomes. The AQAA tells us of improvements that have been made since our last Key Inspection visit We have started converting former double rooms to premium rooms. Five members of Staff and the Home Manager have commenced a training program to improve dignity in care and in turn train all staff members at St. Andrews Lodge. We have improved the environment, especially the garden areas. We have improved the staff training and are continuing to do so. Feedback from relatives and professional visitors has been more specifically requested to help us improve our service. What are we going to do as a result of this annual service review? The next inspection of this service will be based on the Fess and Frequency Regulations 2007 and the assessment of risk of the service. Further clarity will become evident as the new registration and inspection system under the Health and Social Care Act 2008 is confirmed. Annual Service Review Page 5 of 6 Reader Information
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