Inspection on 28/11/06 for Stokeleigh Lodge

This inspection was carried out on 28th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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

Stokeleigh Lodge 26/01/10

Stokeleigh Lodge 10/11/08

Stokeleigh Lodge 03/03/06

Stokeleigh Lodge 27/07/05

Stokeleigh Lodge 20/03/05

Stokeleigh Lodge 28/09/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Stokeleigh Lodge Stokeleigh Lodge 3 Downs Park West Westbury Park Bristol BS6 7QQ Lead Inspector Wendy Kirby Key Unannounced Inspection 28th November 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 Stokeleigh Lodge DS0000026503.V320652.R01.S.doc Version 5.2 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. Stokeleigh Lodge DS0000026503.V320652.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Stokeleigh Lodge Address Stokeleigh Lodge 3 Downs Park West Westbury Park Bristol BS6 7QQ 0117 9624065 0117 9624065 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) Mrs Lyn R Farrall-Miles Dawn Sherwood Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places Stokeleigh Lodge DS0000026503.V320652.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate 17 persons aged 65 years and over requiring personal care 3rd March 2006 Date of last inspection Brief Description of the Service: Stokeleigh Lodge is a privately owned home that is registered with the Commission for Social Care Inspection to provide personal care and accommodation for up to 17 people who are 65 years and over. The premises are situated close to Durdham Downs and have been extended and adapted over time to meet the needs of the elderly. There are two additional floors, which are accessible via a stair lift. The house is residential in style and blends in well within the neighbourhood. It is also close to many local amenities and facilities. The cost per week to reside at Stokeleigh Lodge ranges from £364.00 to £593.00. Fees are reviewed annually. This weekly fee does not include provision for items such as hairdressing, chiropody, dental, ophthalmic, or audiology services. Prospective residents can be provided with information about the home by accessing the Service Users Guide, which will detail the services and facilities available at the home. Stokeleigh Lodge DS0000026503.V320652.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector sent questionnaires “Have your say” to all residents in the home prior to the inspection and eleven were completed and returned. “Comment Cards” were also sent to relatives, visitors and visiting health and social care professionals, seventeen of these were also completed and returned. Information from these has been collated and is detailed throughout the report. As part of this unannounced inspection the quality of information given to people about the care home was looked at. People who use services were also spoken to, to see if they could understand this information and how it helped them to make choices. The information included the service user’s guide (sometimes called a brochure or prospectus), statement of terms and conditions (also known as contracts of care) and the complaints procedure. These findings will be used as part of a wider study that CSCI are carrying out about the information that people get about care homes for older people. This report will be published in May 2007. Further information on this can be found on our website www.csci.org.uk The inspector spent time throughout the visit in discussions with the registered provider, manager and staff; a number of records and files relating to the dayto-day running and management of the home were examined. Four residents were case tracked. Their care plans and care files were examined. The inspector had discussions with the residents and observed them going about their daily routines. The inspector toured the premises accompanied by the manager. Feedback was given on the outcome of the inspection. What the service does well: Admission procedures are resident focused and supportive to residents. Care plans accurately reflect the residents’ needs and how they will be met. Systems are in place to help ensure that there is consistency in assessing, planning, implementing and evaluating the resident’s care at the required times. Stokeleigh Lodge DS0000026503.V320652.R01.S.doc Version 5.2 Page 6 Staff have a good awareness of individuals’ needs and treat the residents in a warm and respectful manner, which means that they can expect to receive care and support in a sensitive way. There are safe systems of medication. Residents benefit from a varied activities programme, which is both enjoyable, stimulating and meets individual preferences and expectations. Meals are well presented and menus verify a healthy well balanced diet for all residents who benefit from a wide variety of choice. The home is comfortable, tastefully decorated and furnished. It provides a safe, peaceful and well-maintained environment for the residents. The homes outdoor surroundings meet the residents needs and provides great pleasure and enjoyment to them. Adequate staffing levels help to ensure that resident’s needs are met. Staffing levels are increased when the dependency levels of the residents change. Staff training is well attended and should ensure that residents are supported by competent and qualified staff. The recruitment procedure is robust and serves to protect vulnerable residents. The home is well organised and managed by an effective, stable management team that promotes the views and interests of the residents. Stokeleigh Lodge provides a good standard of care to its residents, who appear to be happy with the service they receive and are content with their daily lives. What has improved since the last inspection? The home consistently continues to demonstrate good practise and all requirements set at the last inspection have been met and are detailed throughout the report. Environmentally the home continues to upgrade and refurbish parts of the home as required. Since the last inspection new showers have been provided on two floors of the home, new radiator covers have been fitted to further protect the residents, the dining room and some bedrooms have been redecorated and some carpets have been replaced. Stokeleigh Lodge DS0000026503.V320652.R01.S.doc Version 5.2 Page 7 As detailed in the report plans are proposed to upgrade the kitchen and to replace the conservatory roof. 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. The summary of this inspection report can be made available in other formats on request. Stokeleigh Lodge DS0000026503.V320652.R01.S.doc Version 5.2 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 Stokeleigh Lodge DS0000026503.V320652.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents or their families have all relevant information to make a decision about the nature of the home. Residents receive a contract and written terms and conditions on admission to the home Prospective residents needs are assessed prior to admission to determine the suitability of placement to ensure that their needs can be met. Trial visits give prospective residents an opportunity to assess the nature of the home. Stokeleigh Lodge DS0000026503.V320652.R01.S.doc Version 5.2 Page 10 EVIDENCE: It was noted at the previous inspection that there were areas, which need to be included in the Statement of Purpose with reference to Schedule 1 of the Care Standards act and this has now been met. Through discussions with residents in the home and residents surveys it was confirmed that they and their families had received adequate information about the home prior to admission. Comments included, “Staff were very helpful to my family, they had looked at several homes before choosing Stokeleigh Lodge”. Residents’ files contained contracts and terms and conditions, which are signed on admission. Nine residents confirmed in their surveys that they had received a contract and two residents who didn’t know said that they thought their families had signed contracts on their behalf. The residents’ records and discussions with the residents and manager confirmed that a letter is sent to the residents notifying them of any changes in the fees. The prospective resident, family and carers are involved in the pre-admission and all information is used to determine the suitability of the placement. The assessments are based on the activities of daily living and a dependency level is calculated, this should help ensure that residents needs can be met by the home prior to admission. Where possible the manager had also obtained comprehensive assessments and care plans from other professionals involved for example, social workers and hospital staff. Prospective residents are encouraged to visit the home either for the day or perhaps for lunch dependent on their wishes. One resident stated,” I visited the home twice before moving in to meet with staff, and residents and I stayed for lunch”. A month’s trial period on both sides is usually undertaken to ensure that everyone is happy with the arrangements and to ensure that the placement is suitable. Stokeleigh Lodge DS0000026503.V320652.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service has good systems for meeting and monitoring residents’ health and personal care needs in consultation with residents. There are safe systems of practice in receiving, storing, administering, and disposing of drugs. Staff were able to demonstrate a good awareness of individuals’ needs and treat the residents in a warm and respectful manner, which means that they can expect to receive care and support in a sensitive way. EVIDENCE: From the pre admission assessments the staff are able to develop a set of care plans based on identified needs. During the first months trial period the residents’ plans are reviewed weekly and developed accordingly. Stokeleigh Lodge DS0000026503.V320652.R01.S.doc Version 5.2 Page 12 It was evident following previous requirements that the manager and her staff had worked hard in developing the residents care files, which contain more detail and are person centred. All records evidenced consistency in assessing, planning and evaluating the resident’s care on a regular basis. The home conducts regular care review meetings for each resident, which includes the involvement of family members and key worker wherever possible. One relative stated, “We are always kept informed of any problems relating to my relatives care and of any problems that may have arisen”. Staff were able to demonstrate good relationships with individuals and were knowledgeable about the care needs of the residents living in the home. Records of the General Practitioner (GP) visits with residents and the outcomes were documented. Specialist referrals and visits from other professionals including District Nurses, Chiropractors, Dentists and Opticians were also seen. All residents’ surveys stated that they always felt that they received the medical support they needed. Visiting health professionals’ comment cards stated, “Any advice we give to staff is readily accepted and acted upon ”, “I am always impressed by the caring, efficient and compassionate nature of the staff” and “The quality of care is always of a high standard”. Policies and procedures for receiving, storing, administering and disposing of medications were examined and discussed with the manager; all systems in place are effective and well managed. The home operates a monitored dosage system for the administration of medication, which is supplied at regular intervals by the local pharmacist. The GP’s conduct a medication review for all residents every six months. The home also keeps an accurate stock check of medicines given on an as required basis. Fridge temperatures are recorded daily. The administration charts were legible and continuity of administration was shown with a signature from the person dispensing. Staff were witnessed knocking on residents doors before entering confirming respect for the residents individual privacy and dignity at all times. One relative stated, “My parent is well cared for and treated respectfully”. All rooms have a telephone point from which residents can make and receive calls. Private telephone lines can be installed. Stokeleigh Lodge DS0000026503.V320652.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are encouraged and supported to live a lifestyle, which is both enjoyable, stimulating and meets individual preferences and expectations. Residents maintain family contact and staff encourage family and friends to join in with activities and any outings. Relatives feel they can advocate openly on behalf on their relative. Residents receive a varied and wholesome diet that they are able to influence. EVIDENCE: In consultation with the residents’ staff develop a monthly timetable of activities and forthcoming events; this information is displayed on the residents’ notice board. Residents agreed that there were always activities and events arranged that were suitable to their preferences. Stokeleigh Lodge DS0000026503.V320652.R01.S.doc Version 5.2 Page 14 Weekly trips are arranged and residents enjoy going out for lunch, shopping, and visiting places of interest. Other events organised on a regular basis include visiting the local Television Studio, attending “Common Ground” at the local Methodist church for afternoon tea with the Bristol ladies choir and watching shows performed by the “Westbury Park Players” The residents also enjoy regular musical entertainers who visit the home and activities provided throughout the week include, indoor games, quiz time, arts and crafts and reminiscence therapy. Special events are arranged throughout the year. Events arranged this month include the Christmas Party, a performance by the “Failand Drama Club” and “Winter Wonderland” a musical show performed by a travelling theatre company. Residents are supported to attend their local place of worship and at present one resident attends church every Sunday. Residents are free to worship as they wish and any arrangements for services or communal prayers within the home are made in accordance with residents’ wishes. The home has three monthly residents meeting which are well attended and minutes are taken. The minutes evidenced that residents’ participation is encouraged and that they are supported to make decisions and choices about the lifestyle they wish to live and the home they live in. At the last meeting residents had expressed their views on home improvements and requested higher wattage bulbs throughout the home, cold beverages to made available during the day in the lounge and discussions about menus and future events to be organised. The home operates an open door policy for visitors to the home. All relative/visitors comment cards stated that they feel welcome at the home at any time. One relative said, “The atmosphere of the home is always upbeat with a happy feel”. The dining area was light, spacious and the tables were attractively laid with tablecloths and condiments. The inspector spent time with the cook who was relatively new and demonstrated a competent awareness of individual requirements and needs of the residents, including personal preferences. It was evident that the cook was very enthusiastic about her role and spends time with the residents on a daily basis to see if residents have enjoyed their meal and if they are happy with the menus. The menu rota displays traditional meals and choice is available at each setting. The menus are reviewed to reflect seasonal trends and availability of produce. Extras are ordered on request for birthdays and special occasions. Stokeleigh Lodge DS0000026503.V320652.R01.S.doc Version 5.2 Page 15 At the request of the residents the home now has “themed days” whereby food is prepared relating to a particular country for example Italy and the dining room and tables are also decorated to further create the ambience required. Surveys confirmed that residents were generally satisfied with the meals provided. Comments included, “The food is good, with choice of meals and they are well presented”. One resident asked that more fruit should be made available and this was discussed with the manager and the cook. The inspector was shown a large store of fresh fruit and vegetables and it was agreed that residents should be informed at the next meeting of fresh fruit availability. The kitchen was clean, however some areas particularly the kitchen units and worktops were quite old, marked, chipped and in need of replacement. Discussions with the owner, manager and cook confirmed that although the kitchen had had previous revamping over the years it was now in need of replacement and that this was going to be addressed in the near future. Documentation was provided to show the inspector that required temperature checks were being carried out on fridges and freezers and that food was also being probed after being cooked before serving. Stokeleigh Lodge DS0000026503.V320652.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are robust policies in place to manage complaints or allegations of abuse. There are good arrangements in place for staff training and awareness of protection of vulnerable adults EVIDENCE: A copy of the complaints procedure is on display in the reception area, which means people will know how to obtain the required information if they want to make a complaint. There have been no complaints received. Any concerns that residents or visitors may have are dealt with on the spot and recorded in the daily record and this information is cascaded to all staff during handover time. Stokeleigh Lodge DS0000026503.V320652.R01.S.doc Version 5.2 Page 17 Discussions with residents and their surveys confirmed that they knew who to talk if they were not happy and how to make a complaint. Comments included, “I would be happy to speak to the manager or any of the staff” and “If I wished to make a formal complaint I would prefer to speak to my son and daughter-in-law first”. Relatives and visitors confirmed in the comment cards, that they were aware of the homes complaints policy and procedure. The inspector was informed that the home actively promotes staff training and education in the protection of vulnerable adults on induction and by attending training on the Protection of Vulnerable Adults through Bristol City Council. Staff training records evidenced this commitment. A number of staff are undertaking the National Vocational Qualification in care award, and a component of the award addresses issues around the topic of the protection of vulnerable adults from abuse. There are procedures as well as a range of guidance information on the topic of protection of vulnerable adults from abuse’ including the Local Authority “No Secrets” document. Following a requirement at the previous inspection the Protection of Vulnerable Adults procedure and policy has been amended and is in line with Bristol City Council’s No Secrets Guidance. The availability of this information should increase staff awareness and understanding of their role in protecting vulnerable adults who live at the home. Stokeleigh Lodge DS0000026503.V320652.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,23,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is comfortable, tastefully decorated and furnished. It provides a safe, peaceful environment for the residents. The home is clean, pleasant and hygienic. EVIDENCE: As their brochure states Stokeleigh Lodge has many original period features with a pretty, mature garden and patio area overlooking the beautiful parkland of Durdham Down. Stokeleigh Lodge DS0000026503.V320652.R01.S.doc Version 5.2 Page 19 All areas of the home are tastefully decorated, furnished to a good standard, and well maintained. Great attention has been given to ensure that all areas are homely. Residents are supported to personalise their bedrooms with pictures and ornaments and are able to bring items of furniture should they wish. Although plans are currently being made to replace the roof the conservatory adds a pleasing space for residents to use and overlooks the garden with wellstocked flowerbeds, established trees and shrubs. There are various semiprivate seating areas with plenty of sun screening. The gardens provide peace, tranquillity and enjoyment for the residents and visitors throughout the year. Residents were making full use of these areas and their bedrooms on the day of the inspection. The home was clean and smelled fresh and pleasant throughout. The home employs domestic staff on a daily basis. Residents’ surveys confirmed that the home is always fresh and clean and comments included, “There are very good standards of cleaning in all rooms” and “The home is spotless all the time. Stokeleigh Lodge DS0000026503.V320652.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Adequate staffing levels help to ensure that resident’s needs are met. Residents are supported and protected by the homes recruitment policy. The residents are cared for by caring staff that are trained and supported by management. EVIDENCE: The manager ensures that staffing levels are indicative of the needs and levels of care required by the residents twenty-four hours a day. The workforce at Stokeleigh Lodge is relatively small due to the size of the home. Staff are very loyal to the home and its residents and many have worked there a long time. All residents’ surveys agreed that staff were usually available when they needed them and listened and acted upon what the residents say. Stokeleigh Lodge DS0000026503.V320652.R01.S.doc Version 5.2 Page 21 Comments from residents surveys included, “Staff seem a little overstretched during busy times” and “Staff are always friendly and accessible”. Several residents’ and relatives expressed very positive views about staff and the care they receive providing such comments, “All the staff at Stokeleigh are very caring and are always happy to help”,” If I wanted anything I would only need to ask the staff” and “The home has always given me the greatest care”. The recruitment process was examined and all staff records examined showed that the home follows a robust recruitment procedure. Records contained application forms, references, and a CRB (Criminal Records Bureau) disclosure. There is an induction programme, which covers all mandatory training, including Fire, Manual Handling, and Health and Safety. The home has a mentor system where all new staff are linked with and shadow a senior staff member during each shift to enable continuity and continued training throughout the induction process. At the previous inspection it was discussed that some residents were showing signs of early onset dementia and it was discussed with the manager how training in dealing with dementia would benefit the residents. The manager and staff are conscientious in attending training relevant to the care needs of the residents, which has included this year, “Dementia Awareness”, “Diabetes Awareness”, and “Coping with Bereavement and Loss”. The home continues to support their staff with NVQ training and the enrolling programme continues. The training folder was looked at which contained a training matrix and staff certificates for achievement and attendance were on file. The inspector spent some time throughout the day observing staff carrying out their duties and assisting residents. Staff were respectful, warm in manner, good humoured and sensitive towards the residents. Stokeleigh Lodge DS0000026503.V320652.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,37,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs and best interests are central to the management approach in the home. Good accounting methods are adopted and policies and procedures are followed correctly when handling residents’ personal money. Staff receive appropriate supervision. The health and safety of residents, staff, and visitors is protected. Stokeleigh Lodge DS0000026503.V320652.R01.S.doc Version 5.2 Page 23 EVIDENCE: Since the last inspection Dawn Sherwood, has successfully completed her “Fit Persons Interview” with the Commission for Social Care Inspection. She had previously worked at Stokeleigh Lodge for seven years prior to taking the position of manager and has good relationships with the residents and staff group. It was confirmed at the last inspection that Dawn had already made positive changes, such as improving systems of communication and recording of information regarding the resident’s well-being. She has worked very hard over the last year with the support of the registered provider and staff group and continues to develop new initiatives demonstrating new confidence within her new role. It was evident from discussions with the management team and staff that the home has a stable team that supports a commitment to providing quality care for the benefit of the residents. There was a high degree of satisfaction expressed by all of the residents, relatives and visitors who stated, “We are pleased that our relative is in a comfortable well run residential home”, “My relative thrives in this home”, and “A very well run home where staff take a personal interest in all their residents”. Based on the comments made and through the inspectors observation it is evident that the home is run in their best interests and to ensure their needs are being met. The home continues to work hard developing formal quality assurance and has completed an audit this year to assess the satisfaction of residents with regards to the service that the home provides by asking residents, relatives and visitors to complete surveys. The results and comments from the surveys were very positive. Information from the surveys is collated and documented effectively. The results will enable the home to identify all strengths and any weaknesses within the service they provide. Each resident is responsible for his or her own money and a locked facility is provided in each room. Some residents choose to pay for sundries direct for example to the hairdresser and chiropodist, whilst others prefer to be invoiced at the end of each month. The policy of the home is to not hold any amounts of cash for the residents. If residents choose not to keep money in the home other suitable arrangements are made via a representative such as a family member or solicitor. Stokeleigh Lodge DS0000026503.V320652.R01.S.doc Version 5.2 Page 24 There is an annual appraisal process, which ties in with the supervision arrangements. The management have established a formal recorded supervision procedure for all staff. A plan is devised for discussion relating to the residents, work issues, staff issues, personal development and training. The recorded outcomes of the supervision evidenced the effectiveness of the sessions. Some of the Health and safety records in the home were examined. Documentation showed that relevant checks were maintained correctly and at the required intervals including all fire alarms and equipment and emergency lighting. The homes records showed all necessary service contracts were up to date including, gas and electrical services and the stair lift. The fire logbook evidenced compliance to the weekly, monthly and annual checks alongside records of staff training and drills completed, records clearly identified that all members of staff have been present during fire drills as recommended by the Fire Prevention Officer. All night staff undertake this on a three-monthly basis, and day staff six-monthly. Stokeleigh Lodge DS0000026503.V320652.R01.S.doc Version 5.2 Page 25 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 3 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 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 X X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X N/A X 3 3 Stokeleigh Lodge DS0000026503.V320652.R01.S.doc Version 5.2 Page 26 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. Standard Regulation Requirement Timescale for action 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 Stokeleigh Lodge DS0000026503.V320652.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Stokeleigh Lodge DS0000026503.V320652.R01.S.doc Version 5.2 Page 28 - 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!