Inspection on 01/06/05 for St Davids Lodge

This inspection was carried out on 1st June 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

St Davids Lodge 19/05/09

St Davids Lodge 21/05/08

St Davids Lodge 23/05/07

St Davids Lodge 16/05/06

St Davids Lodge 02/11/05

St Davids Lodge 08/02/05

St Davids Lodge 26/08/04

St Davids Lodge 04/02/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE St Davids Lodge 98 Lodge Causeway Fishponds Bristol BS16 3JP Lead Inspector Sandra Jones Announced 1 June 2005 st 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. St Davids Lodge D56_DO5_S26625_StDavidsLodge_V221142_010605_Stage4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service cSt Davids Lodge Address 98 Lodge Causeway Fishponds Bristol BS16 3JP 0117 9656965 0117 9656965 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) Mrs Hazel Pryce-Jones Mrs Hazel Pryce-Jones Care Home only 11 Category(ies) of LD(E),11 registration, with number LD,11 of places St Davids Lodge D56_DO5_S26625_StDavidsLodge_V221142_010605_Stage4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: May accommodate up to 11 persons aged 50 years and over Date of last inspection 8-Feb-2005 Brief Description of the Service: St David’s Lodge is a care home for people with learning disabilities. Since conducting the last inspection, the service provider has sought to increase the registered numbers. The application was successful and the home is now registered to accommodate 11 people with learning disabilities over 50 years. The property is situated on the Lodge Causeway, close to the Fishponds Road, shops, other amenities and bus routes. The property is detached and arranged over two floors with shared space on the ground floor and personal space on both floors. It has the appearance of a domestic dwelling and blends well with its local environment. St Davids Lodge D56_DO5_S26625_StDavidsLodge_V221142_010605_Stage4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was conducted on an announced basis in June 2005. The interaction between staff and residents was observed both directly and indirectly. A pre-inspection questionnaire was completed by the service provider and forwarded to the local CSCI office in advance of the inspection. Records were examined and residents’ feedback was sought to confirm the care practices in place at the home. There have been no additional visits to the home. The staff have kept the local CSCI office informed via Regulation 37 notifications of accidents and occurrences in the home. A condition of registration is in place, for the home to accommodate up to eleven individuals over the age of 50 years and over with learning disabilities. Four residents agreed to give feedback on the standards of care and one person refused. What the service does well: What has improved since the last inspection? Since the last inspection individual profiles have been introduced. Members of staff commented that the team has become more stable and clear directions have improved the working environment. St Davids Lodge D56_DO5_S26625_StDavidsLodge_V221142_010605_Stage4.doc Version 1.40 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 Davids Lodge D56_DO5_S26625_StDavidsLodge_V221142_010605_Stage4.doc Version 1.40 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 St Davids Lodge D56_DO5_S26625_StDavidsLodge_V221142_010605_Stage4.doc Version 1.40 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) 1, 3 & 5 Admissions are based on full assessments and the staff at the home follow the policy. Introductory and trial visits are offered to all potential residents to the home. The criteria for admission to the home must be clarified and included within the Statement of Purpose. EVIDENCE: The home’s Statement of Purpose describes the steps to be followed for potential referrals to the home. It reports that all admissions are based on a full assessment and introductory and trial periods are offered to all potential residents. In terms of the criteria for admission, more detail regarding the accommodation that can and cannot be offered must be listed. Two residents have been admitted to the home since the last inspection. As these individuals transferred within the organisation, their existing care plans were used as the assessment for accommodation at the home. From the St Davids Lodge D56_DO5_S26625_StDavidsLodge_V221142_010605_Stage4.doc Version 1.40 Page 9 documentation available, both residents meet the criteria for accommodation at the home. St Davids Lodge D56_DO5_S26625_StDavidsLodge_V221142_010605_Stage4.doc Version 1.40 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, 9, 10, 11 Individual profiles clearly describe needs, likes, dislikes and preferred routines but an action plan must be devised to guide staff on meeting the needs and evidence of the person’s agreement must be provided. Residents’ right to privacy and dignity is integrated into the approach to care. Procedures based on “End of Life” plans are in place. A procedure for unexpected death must be added. Safe systems for the administration, recording and ordering of medications are in place. EVIDENCE: The placing authority convened reviews meetings for four residents, with the person, their representatives and staff. For all other residents, the service provider convened review meetings. The individual profiles provide an account of the persons needs, with their likes, dislikes and preferred routines. An St Davids Lodge D56_DO5_S26625_StDavidsLodge_V221142_010605_Stage4.doc Version 1.40 Page 11 action plan must be devised to guide the staff to meet the individuals needs. The profiles must evidence that the resident agrees with the plan of action. The Privacy and Dignity policy is incorporated in the Statement of Purpose’s principles of care. Within the individuals profiles their preferred routines evidences that residents right to privacy and dignity is integrated into the care delivery. Residents confirmed that staff observe their right to dignity and privacy by knocking on their bedroom door and waiting for an invitation to enter. Personal care is undertaken in private by staff was an example used by residents about staff observing their right to dignity. Within the admission criteria, the arrangements for existing residents that have a diagnosis of terminal care must be listed. A procedure must be devised for unexpected deaths must be added to the death of a resident procedure. This will enable staff to contact the necessary agencies in the event of an unexplained death at the home. Prescribed medications are currently administered through a monitored dosage system. Evidence that medications are administered immediately after administration was provided by the administration records sheets. Homely remedies are not administered from a stock supply. The service provider stated that GP’s prescribe analgesics for residents that periodically require analgesics. A record of medications no longer required is maintained, which is countersigned by the pharmacist to indicate receipt of the medication for disposal. St Davids Lodge D56_DO5_S26625_StDavidsLodge_V221142_010605_Stage4.doc Version 1.40 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) 13, 14 & 15 Visitors to the home are welcomed by the staff and visits can be conducted in shared and personal space. Opportunities exist for residents to experience community-based activities. Members of staff enable residents to make choices and control their lives. Meals served at the home are varied and in sufficient quantities. EVIDENCE: The visitor’s policy is included within the home’s Statement of Purpose. It states that visitors are welcome and sets out the expectations of visitors to the home. Visits can take place in the lounge and bedrooms and residents confirmed these arrangements. The visitors book evidenced that friends and family visit their family members living at the home. Six residents currently have structured community-based activities and for the others in-house activities and outings are arranged. Residents at the home reported that puzzles, arts and crafts were the range in-house activities organised by the staff. St Davids Lodge D56_DO5_S26625_StDavidsLodge_V221142_010605_Stage4.doc Version 1.40 Page 13 Residents reported that personal belongings are encouraged and each bedroom reflected the occupant’s personality through their personal items. Residents giving feedback reported that the meals were good and sufficient quantities are served. A rolling menu is in place supplemented by a record of food provided, evidencing that alternatives served and their diet is varied. To ensure residents have their preferred meals served, a list of residents likes and dislikes is kept in the kitchen. The temperature of fridge and freezer temperatures is maintained. St Davids Lodge D56_DO5_S26625_StDavidsLodge_V221142_010605_Stage4.doc Version 1.40 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 & 18 Records and residents comments confirmed that complaints are taken seriously and acted upon by the staff. Policies and procedures that evidence a commitment to safeguard residents from abuse are in place but this commitment has yet to be underpinned by relevant training. EVIDENCE: The records of complaints received at the home indicated that since the last inspection one complaint was received from a relative. It was based on personal care tasks and from the records action was taken, by the service provider to resolve the complaint. Residents giving feedback confirmed that the service provider and staff could be approached with complaints. Their confidence that staff would take their complaints seriously was expressed through their comments. Policies and procedures about safeguarding residents from abuse are in place at the home. The service provider and staff must attend POVA training to ensure their awareness of multi-agency responsibilities. St Davids Lodge D56_DO5_S26625_StDavidsLodge_V221142_010605_Stage4.doc Version 1.40 Page 15 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) These standards were not part of the focus for this inspection. EVIDENCE: St Davids Lodge D56_DO5_S26625_StDavidsLodge_V221142_010605_Stage4.doc Version 1.40 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 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, 29 & 30 Staffing levels in place meet the current needs of the residents accommodated. Recruitment procedures in place ensure that the staff employed are suitable to work with vulnerable adults. Training that includes induction for new staff must be provided to ensure the staff are competent to meet the residents needs. NVQ level 2 takeup also needs to improve. EVIDENCE: The rota in place indicates that two staff are on duty throughout the day, with ancillary and catering staff for cleaning and cooking. At night one person is awake and one sleeps in the premises. For the most recent employee, a completed application for, one reference and evidence of a request for CRB is held at the home. Interim measures while the CRB checks are in progress were taken with POVA first check. Structured in-house training is not currently in place, although training packs that follow current good practice guidelines are in place. The service provider must establish a training programme that includes induction training for new staff to ensure they are competent to meet the needs of the residents accommodated. St Davids Lodge D56_DO5_S26625_StDavidsLodge_V221142_010605_Stage4.doc Version 1.40 Page 17 Two staff are currently undertaking NVQ level 2 training. As fourteen staff are employed at the home, a further five staff must undertake NVQ level 2 to meet the NMS of 50 staff to be qualified to NVQ level2. St Davids Lodge D56_DO5_S26625_StDavidsLodge_V221142_010605_Stage4.doc Version 1.40 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 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) 35, 36 & 37 Records that relate to fees charged, cash in safekeeping and fire safety were accurate and up to date and were therefore helping to safeguard residents. Members of staff are not appropriately supervised. They must have an annual appraisal and receive individual supervision. EVIDENCE: A record that lists the weekly fees with the sources that contribute towards the fees is available. These showed that the current weekly charge ranges from £511.13 - £788.28 per week. Facilities for the safekeeping of cash exist at the home and individual records for residents with cash in safekeeping described each transaction. From the sample check of cash in safekeeping, it is evident that the records are up to date and accurate. St Davids Lodge D56_DO5_S26625_StDavidsLodge_V221142_010605_Stage4.doc Version 1.40 Page 19 The records that relate to fire safety policies, procedures, checks and practices were examined. These showed that the checks and practices are conducted at the stipulated frequencies. The service provider must introduce a system of appraisal and supervision at the home. Individual supervision must follow annual appraisals to ensure staff’s performance is monitored and their development needs are identified. St Davids Lodge D56_DO5_S26625_StDavidsLodge_V221142_010605_Stage4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x 2 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 3 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 3 COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 3 28 x 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x x x x 3 2 x x St Davids Lodge D56_DO5_S26625_StDavidsLodge_V221142_010605_Stage4.doc Version 1.40 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 Standard 5 Regulation Regulation 4(1)(c) Schedule1 .8 Regulation 15 Regulation 12 Regulation 18 Requirement The criteria for admission to the home must be clarified and added to the Statement of Purpose. Action plans with the signature of the resident must be developed from the individual profiles A procedure for unexpected deaths must be developed. A training programme with timescales must be developed and added to this response. Induction for new staff must be provided, with other training to meet the needs of the residents must be provided. Which leads into vocational qualifications. Annual appraisals and individual supervision must be introduced. The service provider and staff must attend POVA training to ensure their awareness of multiagency responsibilities. Timescale for action 30/9/05 2. Standard 7 30/10/05 3. 4. Standard 11 Standard 30 30/9/05 30/11/05 5. 6. Standard 36 Standard 18 Regulation 18 (2) Regulation 13(6) 30/9/05 30/12/05 St Davids Lodge D56_DO5_S26625_StDavidsLodge_V221142_010605_Stage4.doc Version 1.40 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. Refer to Standard Good Practice Recommendations St Davids Lodge D56_DO5_S26625_StDavidsLodge_V221142_010605_Stage4.doc Version 1.40 Page 23 Commission for Social Care Inspection 300 Aztec West Almondsbury South Glos. BS32 4RG 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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