Inspection on 23/05/06 for St Huberts Lodge

This inspection was carried out on 23rd 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 Huberts Lodge 13/11/07

St Huberts Lodge 17/11/05

St Huberts Lodge 19/04/05

St Huberts Lodge 20/10/04

St Huberts Lodge 27/04/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE St Huberts Lodge St Huberts Road Great Harwood Lancashire BB6 7AR Lead Inspector Mrs Janet Proctor Unannounced Inspection 23rd May 2006 09:00 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 Huberts Lodge DS0000009440.V287487.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 Huberts Lodge DS0000009440.V287487.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Huberts Lodge Address St Huberts Road Great Harwood Lancashire BB6 7AR 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) 01254 888581 01254 728668 bugger1@ntlworld.com Mr Thomas Cardwell Mr Ian Cardwell Care Home 13 Category(ies) of Old age, not falling within any other category registration, with number (13) of places St Huberts Lodge DS0000009440.V287487.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th November 2005 Brief Description of the Service: St Huberts Lodge offers care to 13 older people. The building is a large detached house, which has been converted into a care home. It is situated in a residential area of the town of Great Harwood. Opposite the home is a Catholic Church. It is within walking distance of local shops and the town centre. There are 5 double bedrooms, one with an en-suite toilet, and 3 single bedrooms. A hand wash basin is present in all bedrooms. There is one communal toilet on the ground floor and 2 communal bathrooms, with toilet, and 1 communal toilet on its own, on the first floor. There are 2 communal lounges with dining facilities. The first floor can be accessed via a passenger lift. Ramped access is available to the front entrance. Car parking is available to the rear of the home. Information on the home is contained within a Service User’s Guide. A copy of this is kept in the hallway of the home and is also sent out to prospective residents. The charges are from £313-00 to £352-50 per week. Extra charges are made for hairdressing and may be made for escorting residents out of the home. St Huberts Lodge DS0000009440.V287487.R01.S.doc Version 5.1 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 on the 23rd May 2006. There were two Regulation Inspectors involved in the visit. No additional visits have been made since the last inspection on 18th November 2005. The information in this report was gathered from various sources, which included residents, visitors, staff, management, records and observation of care. Wherever possible the views of residents were obtained about their life at the home and their comments have been included in this report. What the service does well: All residents received an assessment before moving into St Hubert’s Lodge. This meant that the manager had the information needed to decide whether the home could meet their needs. If the home could meet their needs the prospective resident received a letter telling them this and arranging their admission. Residents spoken to were very happy with the care they received. They felt they were well looked after. They said, “I’ve lived here for 10 years now. I like it and wouldn’t want to be anywhere else. They’re all very good with me. I’ve always been happy here”, “I’ve settled in well. They look after me and I feel safe” and “The staff are very good, always there to help you. I’ve been here for 4 years and wouldn’t like to live anywhere else.” Residents were able to make choices about their lives, for example when they got up and went to bed. This meant that their daily routines were to their liking. The residents spoken to said, “I get up about 6.30 am. I’ve always got up early” and “I’ve had breakfast in bed for 10 years. I have a lie in until 9.30 and take my time getting up and buzz the staff at 10.30 am to come down. I go to bed at 6.30 pm – I lie in bed and watch TV”. The home provided nourishing and plentiful meals. The residents were very satisfied with the meals they received. They said, “We get fed very well, too much to eat sometimes” and “Cereal, tea and toast, that’s what I have for breakfast. The dinners are very good. We choose what we want at teatime”. A visitor said, “The food’s the best – always what they want.” St Huberts Lodge DS0000009440.V287487.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: The information in the Statement of Purpose and the Service User’s Guide needed to be made clearer about when charges would be made for escorts outside the home. Also what would happen if a place became available in a shared room. This is needed as the majority of rooms at St Hubert’s Lodge are double rooms. Residents should be fully aware of what may happen in the future should they decide to take a place in a shared room. Although the care plans have improved there are still some things that need to be included. There should be more details both in the plans and in the daily notes. This is so that staff can fully meet the residents’ needs and that there is a record of how they are each day to assist in the review of the care plan. It is important that residents are in agreement with the care they are to receive. St Huberts Lodge DS0000009440.V287487.R01.S.doc Version 5.1 Page 7 Therefore, there must be evidence to show that the resident or their relative has been consulted about the care plan. If they do not want to be involved there should be a record to show this. Residents said that there were little activities done with them. They said, “We don’t do much during the day”, “A man comes in once a fortnight and does exercises. We have a prayer meeting every month from C of E Church and it ends up as a social occasion” and “We don’t do much but when you’re 80 you don’t do a lot. I do knitting sometimes. I could do with a bit of something going on”. Although the manager said that he did a lot with the residents there were no records to show this. More activities must be provided to ensure that residents’ social and recreational needs are met. A resident said, “There’s still a problem with the wait for the toilet – it’s a long while sometimes”. The means of providing an additional toilet facility on the ground floor should be explored. This is so that residents do not have to wait to use the toilet. The procedures for obtaining references must be improved. The manager must ensure that the references are from the person requested. The references must include one from the last employer. This is so that the recruitment procedures ensure that residents are safeguarded. Following employment all new staff must receive a thorough Induction. All staff must receive a minimum of 3 days paid training each year. This training must cover all aspects of care, health and safety, protection of vulnerable adults, moving and handling and fire procedures. This is in order to ensure that all staff are competent and to protect residents and staff. The amount of self-auditing must be extended. This would enable the Manager to identify areas that needed attention and to create an action plan to resolve these. Residents and staff should also be able to make their views about the home known and be assured that these will be considered. 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 Huberts Lodge DS0000009440.V287487.R01.S.doc Version 5.1 Page 8 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 Huberts Lodge DS0000009440.V287487.R01.S.doc Version 5.1 Page 9 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): 1, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents could be confident that the home could meet their needs. This was because they had their needs assessed before moving into the home and received a letter confirming the home could meet these needs. The information available to residents needed to be reviewed to ensure that it remained fully accurate. EVIDENCE: There was a copy of the combined Service User’s Guide and Statement of Purpose on a small table in the hallway. This was for residents and visitors to read. A letter was seen in the file of a recently admitted resident. This confirmed that the home could meet her needs and that a copy of the Service User’s Guide was enclosed. The resident said “I came for a visit before I came in. They told us a lot about it but I didn’t get a booklet or anything.” The details in the Statement of Purpose and Service User’s Guide did not give full information to residents. It did not describe what would happen if there was a vacancy in a shared room. This is important as residents need to know that their wishes will be taken into account should there be a place available in their room. Also, it did not make it clear when charges would be made for escorts. St Huberts Lodge DS0000009440.V287487.R01.S.doc Version 5.1 Page 10 The file for a resident recently admitted was viewed. This showed that an assessment had been done before the resident came to live at St Hubert’s Lodge. The assessment covered personal and health care needs. It gave sufficient information for the manager to make a decision about whether the prospective resident’s needs could be met at the home. A letter was then sent to the prospective resident telling them whether the home could meet their needs. This documentation was kept on file. Intermediate care was not given at St Hubert’s Lodge. St Huberts Lodge DS0000009440.V287487.R01.S.doc Version 5.1 Page 11 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 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The plans of care had been improved and had more details in them. This meant that residents’ health and personal care needs were more likely to be met. The control of medications had also improved but did not fully safeguard residents. The staff at the home met residents’ personal care needs in private. EVIDENCE: The files for three residents were viewed. One of these had yet to be changed to the new style of care plan documentation. This meant that the information in it was not in as good a detail, full health assessments had not been done and the plan had not been reviewed since last September. The Deputy Manager explained that there were just 2 plans left to be transferred to the new paperwork. The new style plans of care were very good. They included a summary of the care needs, routines and preferences of the resident. This information was individualised and personalised to the resident. More information on the full personal hygiene needs, for example bathing and oral hygiene, was needed. There was a form in one plan of care about being consulted but the resident or St Huberts Lodge DS0000009440.V287487.R01.S.doc Version 5.1 Page 12 their relative had not signed it. There should be a reason stated why consultation has not taken place. The care plans had been reviewed every month and there was an indication of the progress being made. The daily notes should contain more detail about the health, care and condition of the resident. The residents’ health care needs had been assessed. These included: risk of developing pressure sores; nutrition; risk of falls; and moving and handling needs. The directions given to staff on how to meet these needs were individualised to the resident. There was also a psychological assessment for one resident that gave a good description of her mood, reactions and how to approach her about this. There was evidence that the District Nurses were involved in the care of one resident. Also that GP’s were consulted when necessary. A resident said, “I’m fine, very happy. My leg’s still a bother. The District Nurse comes every week without fail to dress it.” All staff who had responsibility for giving out medication had received training from Boots. Some of the staff were also doing a more in-depth Distance Learning course about medications. At the time of inspection no resident was responsible for their own medicines. Some of the care plans viewed had a consent form for the staff to keep and give out the residents’ medication. There was protocol for the use of when required medication seen in the plan of care for one resident who was case-tracked. Variable doses were indicated on the medication record chart. The medications were stored in a metal stand cupboard and a wooden wall cupboard in the hall/porchway of the home. Both cupboards were locked and there was no evidence of over stocking. Some sachets of medication were being stored out of their original container. Therefore they were not named and there were no directions for administration. There was no recording of temperatures of the medication storage areas. No medications needed cold storage. Items used by the District Nurse were stored in a locked cupboard in the dining room. Eye drops were not dated on opening. The Deputy manager said that they were used month on month and disposed of when new stock arrived. Medicines received were being recorded on the chart. There was some confusion about the receipt of one resident’s medications. It was unclear from the records when they had been received and started. Staff said that a book had been started for drugs ordered and received. This was not available at the time of the inspection. The staff at the home did not see the prescriptions as the Community Pharmacist picked these up and then dispensed the medications. A new record sheet was started each week when the new blister pack was started. There were some gaps on the medication records indicating that the resident had not received the medication. There was no reason given for this. Any drugs for return were locked away and then returned using a separate drug return sheet. St Huberts Lodge DS0000009440.V287487.R01.S.doc Version 5.1 Page 13 Medication Administration Record charts examined showed that a second member of staff had witnessed all hand written annotations. Some of the drug names were not spelt correctly. A handwritten instruction had been added to one chart and no one was aware of who had done this. The storage of Controlled Drugs complied with current legislation, but did not meet the National Minimum Standard. The records of Controlled Drugs accurately reflected the stock held. The administration of Controlled Drugs was recorded and witnessed in an appropriate Controlled Drug register. There were good interactions between the staff and the residents and a friendly atmosphere. The District Nurse came to do a dressing for one resident. She asked the resident several times if she “was sure that she wanted to go to her room to have her dressing done”. This implied that it was usually done in the lounge area. Although other residents may say that they do not object to this, for infection control and privacy and dignity reasons the dressing should be done in the resident’s own room. St Huberts Lodge DS0000009440.V287487.R01.S.doc Version 5.1 Page 14 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 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents were able to make choices about their life at the home so that their lifestyle met their preferences. Some residents felt that their social and recreational needs were not being met. Links with family and friends were encouraged, which met some of the resident’s social needs. The food served was nutritious and met residents’ preferences. EVIDENCE: The staff said that residents were encouraged to make choices about their lifestyle whenever they could. There were no fixed getting up and retiring times. One resident felt that she had to wait until her room partner was awake before she got up. The Deputy manager said this was not so and promised to look into the situation. A resident was observed to be shown a pattern book so that she could pick her new curtains. The member of staff spent time spent explaining that they were lined and that she could have tiebacks if she wanted. Residents said that there were little activities done with them. No activities were done during the day of the inspection. At 2.30 pm there were 6 residents in the lounge. 1 was reading, 1 was sleeping, 1 was watching TV, and 3 were looking round not doing anything. The Manager said that he spent a lot of time with the residents, talking and amusing them. He gave example of using a book with old pictures in for reminiscing with 2 residents. Also, he said he St Huberts Lodge DS0000009440.V287487.R01.S.doc Version 5.1 Page 15 spends time singing with them. There were no records to show what activities were done and when. There was information in the Service User’s Guide about visiting. This was described as an “open door” policy. A visitor was spoken to during the inspection. They said, “ If they have to be in a home they couldn’t find a better place. They’re all happy”. A resident said, “My daughter comes and takes me out.” Residents expressed their satisfaction with the food served at the home. The staff knew the residents’ likes and dislikes. They let residents know was for the meal and that they could have an alternative if they wished. Records were kept of the meals served. These specified if resident had anything different at lunchtime but not who has what at teatime. The menu included two roast dinners each week. There were no residents requiring a special diet at the time of the inspection. Fresh vegetables were used every day and fresh fruit was available. St Huberts Lodge DS0000009440.V287487.R01.S.doc Version 5.1 Page 16 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 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents and visitors spoken to were confident that their complaints would be taken seriously and acted upon. The lack of recording systems meant that any concerns may not be formally acknowledged. There were written procedures for responding to an allegation of abuse but the lack of staff training in this subject may potentially result in abusive practices being unrecognised and unreported. EVIDENCE: There was a complaint procedure on display in the hallway. This was also included in the Service User’s Guide. This gave clear directions on who to make a complaint to and that a response would be made within 28 days. The procedure also had the address and telephone number of the Commission. No complaints had been received at the home for several years. There was no designated recording system for any complaints that may be made to the home. No complaints had been made directly to the Commission. All of the residents spoken to were happy with their care at the home. They said that they usually saw the manager on a daily basis and were able to talk to him about any worries or concerns. A visitor said, “I’ve no worries about going to them about anything. They’re always willing to sort things out”. St Huberts Lodge DS0000009440.V287487.R01.S.doc Version 5.1 Page 17 There was a procedure for responding to an allegation or suspicion of abuse. This was in the hallway for anyone to read. It complied with No Secrets and gave good directions to staff on what they should do and who they should report to. There was also a Whistle-blowing procedure. Staff spoken to were aware of reporting allegations and incidents but had still not received training in Protection of Vulnerable Adults. St Huberts Lodge DS0000009440.V287487.R01.S.doc Version 5.1 Page 18 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 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provided comfortable and clean surroundings. This meant that residents were happy with their accommodation at the home. EVIDENCE: Since the previous inspection a number of improvements had been made to the home. These included: repairing the dining room ceiling; fitting new double glazed windows downstairs; new carpets in the dining room, the hallway, the stairs, the upper landing and some bedrooms. Some rooms had been redecorated. One of the first floor bathrooms had been cleared of items stored in it. A work based fire risk assessment had been done and staff had received fire safety training. The lounge and dining room downstairs had a very homely atmosphere. There were ornaments, fresh flowers and knick-knacks. A resident said, “It’s very nice here, very cosy.” There were tables by side of armchairs for drinks. One resident kept a personal photograph by her side on one of these tables so that she could look at it during the day. The doors to the lounge were wedged St Huberts Lodge DS0000009440.V287487.R01.S.doc Version 5.1 Page 19 open. There was domestic style lighting in the main rooms but fluorescent lights in some bedrooms. There was only one communal toilet on ground floor, which meant that residents sometimes had to wait. The home had 5 double bedrooms and 3 single. The bedrooms were individualised and personalised with small belongings of the residents. One of the double bedrooms had an en-suite shower room. The Manager said that when a vacancy came available in a double room, this was managed sensitively. The residents were introduced and allowed to get to know each other before a decision was made about future sharing. One resident had made the decision to move from a double room to a single room. The double bedrooms had a privacy curtain around the wash-basin but did not all have the means to have a privacy screen around the beds. This meant that the resident did not receive care in private if attended to by staff, for example during the night. There was no window restrictor in one of the downstairs bedrooms. As this window opened full it meant that safety and security could not be ensured. The laundry was in the cellar. Access to this did not compromise infection control. The laundry had washable floor and walls. There were 2 washers and 2 driers. There was no sluice programme but they did a hot wash. There was a sink unit with paper towels and gloves available. After drying the linen was sorted upstairs before being returned to residents. Blue and white plastic aprons were available for food and care tasks. Plastic gloves were available. St Huberts Lodge DS0000009440.V287487.R01.S.doc Version 5.1 Page 20 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 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There was sufficient staff on duty for the needs of the residents. The recruitment procedures had improved but still did not fully safeguard residents. The amount of staff training had been increased, but more was needed. This is to ensure that all staff have the skills and knowledge to undertake their duties. EVIDENCE: Staff spoken to said that the staffing situation had improved and that there were generally 2 carers on duty at all times. The Manager said that he brings additional staff in if has to go out on errands or if a resident has high care needs. The recording of this on the duty rota did not make this clear as it appeared that they were on-call and not on duty. There was a Cook on duty each day and 10 hours cleaning provided. The files for two new members of staff were seen. These contained a photograph and proof of identity. The member of staff had filled out an application form that gave their employment history and reasons for leaving previous jobs. A POVA First had been obtained prior to employment starting and a CRB clearance was on file. Two references had been received. For one member of staff these references were addressed to ‘who it may concern’ and were not on letter headed paper. They were also not from last employer, as they were not from the manager or registered provider of the home at which she had been employed. Although they were two separate references they St Huberts Lodge DS0000009440.V287487.R01.S.doc Version 5.1 Page 21 were written on the same paper. The Manager said that contracts were to be developed for staff. A record of First day Induction had just been introduced and this was seen for one new member of staff. The Manager was not aware of the 12 week Induction programme as per Skills For Care and so this was not being done with staff. The amount of training given to staff had increased. However, it was difficult to quickly determine which staff had received what training, as the training matrix was not up to date. Staff confirmed that they had done recent fire safety and health and safety training, but this was not recorded on the matrix. 70 of the care staff had NVQ level 2. St Huberts Lodge DS0000009440.V287487.R01.S.doc Version 5.1 Page 22 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, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager had the necessary experience to manage the home. The residents’ finances were well managed ensuring that these were safeguarded. The internal auditing systems could be improved upon to ensure that the home is run in the best interests of the residents and that the quality of care is appropriate for them. Not all staff had received training in mandatory subjects. This meant that the health, safety and welfare of residents and staff might not be fully promoted and protected. EVIDENCE: The home was managed by one of the registered persons. He had over 20 years experience of running a residential home. He had nearly completed the NVQ level 4 and had done some further training sessions. For example, medications and fire safety. He had a job description detailing his role and St Huberts Lodge DS0000009440.V287487.R01.S.doc Version 5.1 Page 23 responsibilities. The Deputy Manager had also nearly completed the NVQ level 4. There were no formal systems for measuring the quality of the service being provided at St Hubert’s Lodge. There was no annual development plan to show what had been prioritised for the coming year. Residents’ or relatives surveys were not done and residents meetings were not held. This meant that there were no means by which residents could make their views known about the service. The Manager said that he speaks informally to residents on a daily basis and finds things out and sorts them that way. A resident said, “There’s no meetings or questionnaires. I don’t make suggestions, as I don’t like to poke my nose in.” Staff meetings were not held. Again, there were informal systems in place. The Manager said that he meets with the seniors and carers as they come on shift and gives them information. He said he worked alongside them and kept them up to date that way. A member of staff said, “Management are supportive and understanding. I’ve had supervision this year. There’s no staff meetings, I think we should have them. I’m able to make suggestions informally, usually at breaktime.” There was a written report book as well as verbal communication. Policies and procedures were available and had been reviewed in the last 12 months. The Manager collected the pension for one resident. There were records to show the amount of money received and amount paid to the resident. Only the money for this one resident was kept on the premises. There was a safe for this. The balance of money checked against the records and found to be correct. There was a record of charges made to residents and payments received. Supervision was now being done. Records of this were seen in the file for one staff member. The fire alarms were checked weekly. Fire drills were done and the records showed the name of staff attending and comments on the outcome of the drill. Portable Appliance Testing had been done in February and the bath hoist had been serviced on 22/05/06. Training for staff in health and safety issues was not up to date: Moving and handling training was overdue; Protection of Vulnerable Adults training had not done; some staff needed to do basic food hygiene training. Fire training had been done by 7 staff in March 2006. Health and safety training had been done in September 2005 by 6 staff. St Huberts Lodge DS0000009440.V287487.R01.S.doc Version 5.1 Page 24 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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X 2 X X X X 3 STAFFING Standard No Score 27 3 28 4 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X 3 X 2 St Huberts Lodge DS0000009440.V287487.R01.S.doc Version 5.1 Page 25 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 OP1 Regulation 5 Timescale for action The information in the Statement 23/07/06 of Purpose and Service User’s Guide must be accurate and current. Any charges made for escorts must be included in the information. There must be evidence that the 31/08/06 resident or their representative have been consulted about the plan of care. All medications must be stored in 24/05/06 the container in which they are dispensed. Sachets of medication must not be kept loose in the cupboard. All medication administered must 24/05/06 be signed for on a medication administration record. (Previous timescale of 30/04/06 not met). Any reason for omission must be recorded. Staff must ensure that when 24/05/06 they hand write and check medications that all drugs are correctly spelt. Any amendment to the medication record must be signed and witnessed. There must be sufficient and 30/06/06 appropriate activities to meet the needs of the residents DS0000009440.V287487.R01.S.doc Version 5.1 Page 26 Requirement 2 OP7 15(1)(2) (c) 13(2) 3 OP9 4 OP9 13(2) 5 OP9 13(2) 6 OP12 16(2) (n) – (m) St Huberts Lodge 7 OP18 13(6) 8 9 OP19 OP21 16(2)(c) 23(2)(j) 10 OP27 Schedule 4(7) 19(1)(c) 11 OP29 12 13 OP30 OP33 18.1 (c) 24 14 OP38 18(1)(a) All staff must receive training in Protection of Vulnerable Adults. Previous time scale of 28/02/06 not met) Privacy screens must be provided where two people share a room. There must be sufficient numbers of lavatories to meet the needs of the residents.(Previous timescale of 31/03/06) The duty rota must be an accurate record of who was on duty. It must be made clear who is on duty and who is on-call. The manager must ensure the authenticity of all references. One of the references must be from the previous employer.(Previous time scale of 19/11/05 not met) All staff must receive a thorough Induction programme at the start of employment. A system for reviewing and improving the quality of care must be established and maintained.(Previous time scale of 28/02/06 not met) All staff must receive training in: fire safety; infection control; basic food hygiene; and first aid.(Previous time scale of 31/03/06 not met) 31/07/06 31/08/06 30/09/06 31/05/06 24/05/06 31/05/06 30/09/06 30/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations Standard 1 OP1 Information on what would happen if there was a vacancy in a shared room should be included in the Statement of Purpose and Service User’s Guide. St Huberts Lodge DS0000009440.V287487.R01.S.doc Version 5.1 Page 27 2 3 4 5 OP7 OP7 OP7 OP9 Whilst the new care plans are being introduced the current ones should be kept up to date and reflect the risks and needs of the resident. The plan of care should include detailed information on how to meet personal hygiene needs. The daily notes should contain more detail about the health, care and condition of the resident Staff should see prescriptions prior to them being dispensed by the pharmacy. Medicines should be stored at the appropriate temperature. A record of temperature should be maintained for all areas where medicines are kept (fridge should be monitored daily) The opening date should be recorded on eye drops and other items with a short shelf-life 6 7 8 9 10 11 12 13 14 OP10 OP15 OP16 OP19 OP29 OP30 OP30 OP30 OP33 All dressings to wounds should be done in the resident’s own bedroom. This ensures that privacy and dignity and infection control are protected. There should be a record of the food choice made each resident at tea time. There should be a separate recording system for any complaints made to the home. Window restrictors should be fitted to ensure the safety and security of residents. All staff should have a contract that reflects their current job role and hours of work. Now that a record of First Day Induction training has been commenced this should be done for all new employees. All new staff should undertake an Induction programme that meets the specifications of Skills For Care. All staff members should receive 3 days paid training in a 12-month period. Residents’ surveys should be done and the results collated and made available for people to read. St Huberts Lodge DS0000009440.V287487.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB 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 Huberts Lodge DS0000009440.V287487.R01.S.doc Version 5.1 Page 29 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!