Inspection on 02/11/05 for St Davids Lodge

This inspection was carried out on 2nd November 2005.

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 16/05/06

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 2nd November 2005 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.V263749.R01.S.doc Version 5.0 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.V263749.R01.S.doc Version 5.0 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.V263749.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 11 persons aged 50 years and over Date of last inspection 1st June 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.V263749.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over one day with the staff on duty and residents at home. There have been no additional visits to the home since the last inspection. Feedback was sought from residents on the standards of care and from the staff on the conduct of the home. The tour of the premises was part of the inspection process, records examined were used to confirm the findings. What the service does well: What has improved since the last inspection? Since the last inspection, the service provider has conducted assessments on all aspects of the persons’ lives. St Davids Lodge DS0000026625.V263749.R01.S.doc Version 5.0 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 DS0000026625.V263749.R01.S.doc Version 5.0 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.V263749.R01.S.doc Version 5.0 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): This standard was assessed at the previous inspection. EVIDENCE: St Davids Lodge DS0000026625.V263749.R01.S.doc Version 5.0 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 Comprehensive assessments are completed for each person but action plans must be developed from these assessments to provide continuity and consistency of care. Outcome of visits must be recorded to ensure there is clear understanding between professionals. EVIDENCE: The care planning approach has been further developed since the last inspection. Assessments completed focus on all aspects of the person’s needs, i.e. physical, emotional, social, cognitive and health. The format is based on a tick box system with additional comments. The daily routine plan identifies the individuals preferences, possible problems, with the name of the delegated person responsible for managing the routine identified. Action plans must be devised based on drawing the assessments together by describing the need, goal, necessary steps, the person responsible and timescale. St Davids Lodge DS0000026625.V263749.R01.S.doc Version 5.0 Page 10 Residents accommodated are registered with a local GP and records list their visits. Other documentation held within files evidenced that specialist support is sought through hospital referrals. Risk assessments were found completed for residents that require the support of the staff. One resident has a pressure sore which is being managed by the district nurses. Through discussion with the staff, there are inconsistencies with feedback from the district nurses on the healing progress of the wound. It was reported that the nurses do not always carry out changes in dressings. While the home is recording visits, more accurate recording on the outcome of visits must be maintained. Dietician input was sought for this resident and advice regarding the diet to be served is followed. A pressure-relieving mattress was provided some time ago. During the inspection, the GP. was contacted to request a visit for reassessment of the pressure sore, to ensure correct treatment. St Davids Lodge DS0000026625.V263749.R01.S.doc Version 5.0 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 In-house and community based activities take place. Programmes of activities must be developed to fit with residents’ expectations and capabilities. EVIDENCE: Currently five residents have twice weekly community based activities. KeepFit and entertainers visit the home monthly, with other group activities provided by the staff at the home. Assessments are centred on orientation, socialising, cognition, concentration and interests. The assessment format is based on a tick box system with additional space for comments. During the inspection the residents were pursuing leisure interests. Residents were watching the television and making jigsaw puzzles. Members of staff reported that, in the afternoon, in-house activities take place in the conservatory. The staff were observed supporting four residents with making jigsaw puzzles. St Davids Lodge DS0000026625.V263749.R01.S.doc Version 5.0 Page 12 There is one resident that spends leisure time in their bedroom listening to music. This individual stated that listening to music is their preferred leisure interest. Other residents described their leisure interests and hobbies. St Davids Lodge DS0000026625.V263749.R01.S.doc Version 5.0 Page 13 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 Concerns and complaints are taken seriously by the staff indicating that residents’ views are sought. EVIDENCE: Residents giving feedback reported that members of staff would be approached with concerns and complaints. Their comments indicated confidence with the staff who they felt took their concerns seriously. St Davids Lodge DS0000026625.V263749.R01.S.doc Version 5.0 Page 14 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): 19,20,21,22,24 &26 St David’s Lodge has a homely atmosphere but to ensure that residents benefit from their environment, repairs must take place. Communal areas provide residents with sufficient shared space to socialise as a group. The number of toilets, washing and bathing facilities provided meet the needs of the residents. Equipment and aids are provided to assist less mobile residents with moving around the home. Risk assessments for using bedrails must be completed to ensure that the actions are positive and protect the person. For residents to have safe and comfortable private space the following action must be taken: Locking device must be installed in the bedroom that is not lockable, missing handles from bedroom furniture must be replaced and window restrictors installed in upstairs bedrooms, where appropriate. St Davids Lodge DS0000026625.V263749.R01.S.doc Version 5.0 Page 15 The premises are kept clean and free from unpleasant odours. To maintain residents and staff’s safety, COSHH substances must be lockable and the window in the laundry room be repaired. EVIDENCE: St David’s Lodge is located on Lodge Causeway close to the Fishponds Road, shops, amenities and bus routes. The property is within a residential and industrial environment, maintaining an appearance of a domestic dwelling. It is arranged over two floors with bedrooms on both floors and shared space on the ground floor. It was understood from the members of staff on duty that the chairs are being replaced indicating that furniture is renewed as required. 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 current ratio of bathrooms is five people sharing one bathroom, which is above the NMS of eight people sharing one bathroom. Members of staff reported that most residents use the recently installed shower on the ground floor and the facility has become very useful. 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 shared by five people. 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. Hoists for transferring residents and lifting equipment are provided for residents that have mobility impairments. With one exception, bedrooms are single. The double bedroom is en-suite offering privacy with personal care. Members of staff gave a definite response regarding personal care provided to the residents that share. It was St Davids Lodge DS0000026625.V263749.R01.S.doc Version 5.0 Page 16 vehemently reported that residents’ privacy is promoted whenever personal care tasks are undertaken. Bedrooms contain a combination of the home’s furniture and personal belongings and most are are furnished and equipped to meet the needs of the individual. Bedrails are used in a number of beds. However, risk assessments that evidence that bedrails are appropriate and reduce the level of risk are not in place. Risk assessments must be completed for residents that have bedrails. In bedrooms 4,5,7,8 and 9, windows open fully, increasing the potential of a resident falling from an upstairs window. The vulnerability of the person must be assessed and where necessary window restrictors must be installed. Bedroom 10 is not currently lockable. Doors to residents private accommodation must be fitted with locks which are accessible to the staff in the event of an emergency. While members of staff reported that furniture and furnishings were being replaced, there was furniture with missing handles in a number of bedrooms. Furniture that has missing handles must be replaced. The laundry room is sited upstairs away from the kitchen. The floor covering impermeable and the walls are painted making the surface readily cleanable: however, the window is broken and must be replaced. The washing machine is suitable for the number of residents accommodated and has a specified programme for disinfection. COSHH substances are kept in a cupboard in the laundry room. However, the cupboard is not secure and the laundry room is not lockable. Hazardous substances must be kept locked to reduce the potential of misuse by residents. St Davids Lodge DS0000026625.V263749.R01.S.doc Version 5.0 Page 17 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 For residents to benefit from a well managed home, the service provider must make a decision about the day-to-day running of the home. Six members of staff are registered on the NVQ level2. EVIDENCE: The duty rota in place indicates that two staff are rostered throughout the day with ancillary staff for cooking and cleaning. At night one person is awake and one sleeps in the premises. The service provider was not on duty on the day of the inspection and had not been rostered for the previous six weeks. The service provider must make a decision about the day-to-day management of the home. Otherwise the service provider must undertake a minimum of 30 hours per week at the home. Staffing levels will be assessed at the next inspection to confirm that there is sufficient staff to meet residents needs. Members of staff on duty stated that there had been a change of training provider since the last inspection. Six members of staff are registered on the NVQ level2 and the assessor is expected to visit on 20/10/05. Staff attended Food Hygiene, Moving and Handling, First Aid and fire training between 2004 and 2005. St Davids Lodge DS0000026625.V263749.R01.S.doc Version 5.0 Page 18 St Davids Lodge DS0000026625.V263749.R01.S.doc Version 5.0 Page 19 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): 36 &38 Individual supervision based on performance and personal development must be introduced to ensure staff are appropriately supervised . Arrangements in place for external contractors to check and service systems and appliances promote residents and staff’s safety. In-house emergency lighting checks must be made monthly to ensure residents safety in the event of a fire. EVIDENCE: Supervision based on the individual’s reflection of training completed takes place with the service provider. Records examined indicated that supervision based on external Foundation training has taken place. However, individual St Davids Lodge DS0000026625.V263749.R01.S.doc Version 5.0 Page 20 supervision based on the staff’s performance and responsibilities of their role have not taken place. 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. Members of staff reported that gloves and aprons are always available at the home. St Davids Lodge DS0000026625.V263749.R01.S.doc Version 5.0 Page 21 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 x x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 x 2 3 3 3 x 2 x 2 STAFFING Standard No Score 27 2 28 3 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x x x x 2 x 2 St Davids Lodge DS0000026625.V263749.R01.S.doc Version 5.0 Page 22 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 individual profiles from the individual profiles and assessments conducted. These plans must show the necessary steps to be taken. (Previously required 1.06.05) A training programme with timescales must be developed and and submitted to CSCI to show how the home will meet mandatory training needs. Induction for new staff must be provided with other training to meet the needs of the residents. (Previously required 1.06.05) Individual supervision, which looks at performance, must be introduced. (Previously required 1.06.05) The service provider and staff must attend POVA training to ensure their awareness of multiagency responsibilities. (Previously required 1.06.05) DS0000026625.V263749.R01.S.doc Timescale for action 30/01/06 2. OP30 18 30/01/06 3. OP36 18 (2) 30/01/06 4. OP18 13(6) 30/12/05 St Davids Lodge Version 5.0 Page 23 5 6 OP8 OP12 7 OP22 8 OP38 9 OP37 10 11 OP37 OP26 17(1)(a)3. Outcomes of visits by other 3(m) health care professional must be detailed. 16(2)(m) From the assessments &12 completed, individual and group activity programmes must be devised. 13(4) Risk assessments must be devised for residents that have bedrails installed and any action resulting from those assessments be taken. 23(2) Window restrictors must be installed, where, all bedrooms must be lockable and missing handles must be replaced. 17(2)Sch. The service provider must work 4.7 at the home for a minimum of 30 hours per week or appoint a manager for the day to day management and put them forward for registration. 23(4)Sch. Ensure emergency lighting 4.14 checks are conducted monthly and recorded. 16(2) The broken window in the laundry room must be replaced and chemicals must be stored in a locked cabinet 30/11/05 30/01/06 30/12/05 28/02/06 04/11/05 04/11/05 30/11/05 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.V263749.R01.S.doc Version 5.0 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. 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