Inspection on 16/05/06 for St Davids Lodge

This inspection was carried out on 16th May 2006.

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 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 Davids Lodge 19/05/09

St Davids Lodge 21/05/08

St Davids Lodge 23/05/07

St Davids Lodge 02/11/05

St Davids Lodge 01/06/05

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 Unannounced Inspection 16th May 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 Davids Lodge DS0000026625.V294397.R01.S.doc Version 5.1 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 Davids Lodge DS0000026625.V294397.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Davids Lodge Address 98 Lodge Causeway Fishponds Bristol BS16 3JP 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) 0117 9656965 0117 9656965 hazelprycejones@hotmail.com Mrs Hazel Pryce-Jones Mr Clive Pryce-Jones Mrs Hazel Pryce-Jones Care Home 11 Category(ies) of Learning disability (11), Learning disability over registration, with number 65 years of age (11) of places St Davids Lodge DS0000026625.V294397.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 11 persons aged 50 years and over Date of last inspection 2nd November 2005 Brief Description of the Service: St Davids 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 DS0000026625.V294397.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was conducted over one day in May 2006 and focused on the assessment of key standards of care. Records were examined and a tour of the premises took place to make judgements on the standards of care. Relative comment cards were sent by the home on behalf of the CSCI to seek their feedback on the standards of care. Residents’ feedback was sought to confirm the standards of care and the members of staff were consulted on the conduct of the home. What the service does well: What has improved since the last inspection? What they could do better: St Davids Lodge DS0000026625.V294397.R01.S.doc Version 5.1 Page 6 One requirement is repeated from previous site visits and the service provider has given assurances that the action will be taken to meet legislation. In adopting a person centred approach, residents will be enabled to have more choice, control over their lives and the support they receive. It is a mechanism for reflecting the needs and preferences of the individual. 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 DS0000026625.V294397.R01.S.doc Version 5.1 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 Davids Lodge DS0000026625.V294397.R01.S.doc Version 5.1 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 Quality in this outcome area is adequate. The service provider considers the suitability of potential residents to the home before admission. Intermediate care is not offered at the home. EVIDENCE: The Statement of Purpose clarifies the procedure for admission to the home. Within the procedure are the arrangements for introductory visits and trial periods. It was understood from the service provider that there are four empty beds and that placements for these beds are actively being sought. There is one potential resident within the home’s category of needs. Referrals are generally from the Local Authority and core assessments are provided from the placing agency. The service provider confirmed that intermediate care is not offered at the home. St Davids Lodge DS0000026625.V294397.R01.S.doc Version 5.1 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 adequate. The care plans include basic information action plans must be developed using a person centred approach to ensure that needs are met in each person’s preferred manner. The home seeks professional advice on health care issues and acts upon it. The home understands the need to comply with the administration, safekeeping and disposal of medications. Policies and procedures demonstrate a clear commitment towards respecting residents’ rights. EVIDENCE: Residents’ case records contain full assessments of needs, care plans and reviews of the plans. Within the records, running reports are kept, along with a current photograph of the person. Pre-service assessments are completed for each person that contains personal information and the initial assessment on their well being. Care plan forms are used to list the needs, goals, steps and responsible person with timescales. The information is basic and not sufficiently specific for staff to follow. The resident’s signature is included St Davids Lodge DS0000026625.V294397.R01.S.doc Version 5.1 Page 10 indicating their input into the process. While the system for gathering information is detailed and completed for each person, the information is not drawn together into an action plan. Risk assessments are completed for residents that have mobility impairments and from the documentation held in files, two residents require assistance with moving around the home. A tick box system is used to assess all areas of the person’s physical capabilities, movement and transfer needs. A safe handling instruction form follows from the assessment. The area of need, equipment to be used and support to be provided is detailed. Risk assessments for bed rails are also in place for residents that are at risk of falling from their bed. There is a tick box system used to identify personal and health care needs. In terms of the personal tasks, the assessments seek to assess the person’s capabilities with bathing, washing, dressing and undressing. Within the assessment there is space for staff to describe the person’s preference, the day and time for the task to be completed. However, each completed assessment is the same. From the assessments, daily and bedtime routine formats should specify preference. Possible problems and the responsible person, with the timescale are listed. While the area of need is specific, preferences about the routine are not incorporated. Assessments for eye care, continence and pressure areas are in place, with a record of health care appointments. Medical appointments are recorded with the time, nature of appointment and outcome of the visit. It is evident that appropriate professional advice is sought. Residents at the home have access to dieticians; attend hospital appointments and district nurse service. Access to NHS facilities is available to the residents. Chiropody, dentist and optician visits are regularly arranged. Running reports are clear about outcome of visits and instructions to be followed. Residents giving feedback during the inspection reported that records are kept about them in the office. The Statement of Purpose clearly sets out the principles of care and describes the staff’s responsibility towards observing residents rights. The case files specify the person’s preferred mode of address. However, a person centred approach to meeting needs, where key elements of rights, choice, independence and choice is not used. Once action plans are developed using this approach, the manner in which rights are respected will be evidenced. Residents consulted during the inspection confirmed that members of staff respect their rights. Examples such as personal care tasks being conducted in private and staff knocking and waiting for an invitation to enter were given. Medication is administered at home by the staff through a monitored dosage system. The records of administration indicate that staff sign the records immediately after administration. There is appropriate use of codes whenever medication is not administered. A record of medication no longer used at the St Davids Lodge DS0000026625.V294397.R01.S.doc Version 5.1 Page 11 home is maintained. It is signed by the pharmacist to evidence receipt of the medication for disposal. St Davids Lodge DS0000026625.V294397.R01.S.doc Version 5.1 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 the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is adequate . Residents are given the opportunity to take part in a variety of activities both within the home and the community, which are arranged after consultation. The home supports open visiting and residents know that they can entertain their family members. Residents are able to have personal possessions in their room and are aware that records are kept about them. Residents have choice of meals at each mealtime and healthy eating is promoted. EVIDENCE: There are individual activities programmes devised from the assessments completed. Three residents currently visit daycentres, one attends five days a week and two, twice weekly. Puzzles, knitting, arts and crafts, baking and board games are organised in-house by the staff. The service provider ensures that outside entertainers visit the home monthly. Aromatherapy, music with instruments, music and movement and sing a long take place at the home each month. Photos of the activities are available and evidence the activities. During the inspection, residents were observed taking part in activities. Residents pursued their leisure interest in the morning and in the afternoon participated in picture bingo. Three residents were consulted on the St Davids Lodge DS0000026625.V294397.R01.S.doc Version 5.1 Page 13 arrangements for activities. Residents described their leisure pursuits and confirmed their participation in the in-house activities. Formal residents meetings are convened and the reports of the two most recent meetings were available. Menu planning was discussed and their input sought. Each person had the opportunity to make suggestions about activities and outings. Residents are informed about events organised by clubs at these forums. The Statement of Purpose defines the visiting policy, which is to welcome visitors at any reasonable time. Visitors to the home must record the date and nature of their visit to the home. From the records one resident has regular visits from family members. Relative surveys were used to seek feedback on the standards of care. At the time of the inspection, one response was received and the responses indicated satisfaction with the standards of care observed. Two residents giving comments during the inspection confirmed that their visitors were welcomed by the staff. It was reported that the conservatory and bedrooms were used for the visits. The service provider stated that the current residents are unable to manage their financial affairs. Payments for fees are done by direct debit directly into the homes account and personal allowances are kept in safekeeping. During the inspection a tour of the home was conducted and bedrooms reflected residents’ personalities. Residents confirmed that the staff encourage them to bring to the home their personal belongings. Residents giving feedback during the inspection stated that the meals were adequate and alternatives are provided. Members of staff consulted confirmed that choices and alternatives must be provided. It was further understood from the staff that generally the menus are devised from knowledge of the residents’ likes and dislikes. The service provider stated that one resident was referred to a dietician. From the documentation held, the menus were thought to be adequate by the dietician. The recommended level for healthy eating was suggested and incorporated into the rolling menus. The staff record the meals served to residents on daily diet sheets – this includes meal choices and alternatives. There was an Environmental Health visit and the two recommendations made following that visit were actioned by the service provider. St Davids Lodge DS0000026625.V294397.R01.S.doc Version 5.1 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 the following standard(s): 16 & 18 Quality in this outcome area is adequate. There is a complaints procedure and residents understand how to make complaints and feel confident to approach the staff. Members of staff know what immediate action to take and when and to whom the incident is to be referred. EVIDENCE: Residents consulted expressed confidence with the staff abilities to resolve complaints. Residents confirmed that the staff can be approached with complaints. There were no complaints received at the home or CSCI since the last inspection. Members of staff consulted were aware of the policies and procedures that safeguard residents from abuse. It was confirmed that training in the principles of abuse and their responsibilities towards reporting poor practice was provided in-house. The service provider and two senior staff attended the Local Authority Protection of Vulnerable Adults (POVA) training. The service provider explained that since the last inspection a training programme was developed since the last inspection, which entails POVA training. All staff must read and sign the No Secrets guidance and copies of the General Social Care Code of Conduct to indicate receipt and understanding of the documentation. Members of staff are currently undertaking the Skills for Council Induction standards, which includes Recognising and Responding to Abuse. Staff must St Davids Lodge DS0000026625.V294397.R01.S.doc Version 5.1 Page 15 watch a video, complete questionnaires and pass the standard with a minimum score of 90 . Staff that do not attain the minimum score must repeat the training. St Davids Lodge DS0000026625.V294397.R01.S.doc Version 5.1 Page 16 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, 21, 22, 24 & 30 Quality in this outcome area is good. The home is homely well lit clean and tidy. Residents have a choice to bring personal items and their rooms reflect their personalities. The shared areas provide a choice of communal space and the home has the necessary equipment to assist residents to move around the home independently. EVIDENCE: St David’s Lodge is located on Lodge Causeway, close to the Fishponds Road, shops, amenities and bus routes. The property is surrounded by residential and industrial environment; it maintains an appearance of a domestic dwelling. It is arranged over two floors with bedrooms on both floors and shared space on the ground floor. St Davids Lodge DS0000026625.V294397.R01.S.doc Version 5.1 Page 17 Shared facilities consist of a lounge/dining area and conservatory. The lounge has seating for eleven residents and in the dining room there is sufficient seating for the residents to have their meals together. The conservatory is used for in-house activities and can seat up to four residents. There is a shower room and toilet on the ground floor and an assisted bathroom upstairs. The ratio of bathrooms is five people sharing one bathroom, which is above the NMS of eight people sharing one bathroom. The bathroom on the first floor has an assisted bath for residents that need support with getting in and out of the bath, with a separate shower and toilet. There is a toilet on each bedroom floor and two bedrooms are en-suite with toilet, hand basin and shower. The seats on the toilets are raised and the ratio is five people sharing. Equipment and aids are provided, to assist less mobile residents with moving around the home. Residents have access to bedrooms and shared space by the provision of a passenger lift to the first floor and a ramp that leads into the building. With one exception, bedrooms are single. The double bedroom is en-suite offering privacy with personal care. Bedrooms contain a combination of the home’s furniture and personal belongings. Most are furnished and equipped to meet the needs of the individual. The laundry room is sited upstairs away from the kitchen. The floor covering is impermeable and the walls are painted making the surface readily cleanable. The washing machine is suitable for the number of residents accommodated and has a specified programme for disinfection. Control of Substances Hazardous to Health (COSHH) substances is kept in a cupboard in the laundry room. St Davids Lodge DS0000026625.V294397.R01.S.doc Version 5.1 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 adequate. Residents feel that staff know what they are meant to do. The service provider has developed a training programme and encourages staff to undertake external qualifications. The recruitment procedure generally meets the regulations and National Minimum Standards. EVIDENCE: At present two care staff are rostered throughout the day with ancillary staff that have a combined role of cooking and cleaning. The service provider is at the home four days each week and at night one person is awake in the home. The service provider stated that there might be changes in the rota to reflect the current number of residents. Residents reported that the staff at the home respected their rights and were available at all times. There are eight staff employed at the home and five are currently registered onto NVQ level 2, with one already completed. Since the last inspection, the service provider has developed a training programme, which entails statutory, POVA and other specific training. It is to be provided in-house through commercially purchased distance learning packages. Generally the staff watch video and complete questionnaires, with the service provider evaluating to assess the staff’s competency. The staff St Davids Lodge DS0000026625.V294397.R01.S.doc Version 5.1 Page 19 have completed modules on delivering personal care, supervision and the role of the care worker. Personnel files were examined. Completed application forms and two written references are kept within their case files. With two exceptions, CRB Disclosures were obtained for all staff, evidence was provided that CRB Disclosures are being processed for the two outstanding staff. St Davids Lodge DS0000026625.V294397.R01.S.doc Version 5.1 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, 35, 36 & 38 Quality in this outcome area is adequate. The service provider has the experience to run the home. The home manages residents’ money on their behalf and there is a system in place to record transactions and accounts for spending. Checks show that records are up to date. The home has a Health and Safety policy, which meets legislation. Members of staff receive regular supervision from the service provider. EVIDENCE: The service provider is rostered to work a minimum of 30 hours over four days. A vacancy for a manager exists and once a manager is recruited the service provider will relinquish the day-to-day management of the home. St Davids Lodge DS0000026625.V294397.R01.S.doc Version 5.1 Page 21 It was understood from the service provider that fees are paid directly into the home’s account and personal allowance is reimbursed to residents. There is a record of the weekly fees charged at the home and for each person there is a breakdown of sources that contribute towards the fees. The fees currently range from £525.82-£810.00 per week. Facilities for the safekeeping of cash and valuables exist at the home. The cash held in safekeeping was checked during the inspection and up to date and accurate records were found. Supervision is organised into training, shadowing and 1:1 sessions. 1:1 supervision is based on work performance and training. From the records examined the service provider has had supervision with each member of staff. Arrangements are in place for external contractors to check and service appliances and systems. Contracts for the transfer of waste are in place, a competent contractor services fire alarm systems annually and portable equipment is checked. Reports for servicing the lift and hoist are in place and up to date. The records that relate to fire safety policies, procedures, checks and practices were examined. The records indicated that with the exception of the emergency lighting, checks and practices are conducted at the stipulated frequencies. St Davids Lodge DS0000026625.V294397.R01.S.doc Version 5.1 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 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 3 10 3 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 3 3 x 3 x 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x x x 3 3 x 3 St Davids Lodge DS0000026625.V294397.R01.S.doc Version 5.1 Page 23 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 OP7 Regulation 15 Requirement Action plans with the signature of the resident must be developed from the assessments conducted. These plans must show the necessary steps to be taken. (Previously required 1.06.05 and 2/11/05) Care plans must be developed using a person centred approach to meeting needs. Timescale for action 30/08/06 2. OP8 12(2) 30/08/06 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 St Davids Lodge DS0000026625.V294397.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Bristol North LO 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. Extracts may not be used or reproduced without the express permission of CSCI St Davids Lodge DS0000026625.V294397.R01.S.doc Version 5.1 Page 25 - 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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