Inspection on 23/01/07 for Suffolk Lodge

This inspection was carried out on 23rd January 2007.

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

Suffolk Lodge 30/01/09

Suffolk Lodge 10/02/06

Suffolk Lodge 20/09/05

Suffolk Lodge 30/11/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Suffolk Lodge Rectory Road Wokingham Berks RG40 1DH Lead Inspector Robert Dawes Unannounced Inspection 23rd January 2007 10:20 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 DS0000031244.V325366.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. DS0000031244.V325366.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Suffolk Lodge Address Rectory Road Wokingham Berks RG40 1DH 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) 0118 979 3202 Wokingham District Council Ms Christine Ann Mitchell Care Home 40 Category(ies) of Dementia (7), Old age, not falling within any registration, with number other category (33) of places DS0000031244.V325366.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th February 2006 Brief Description of the Service: Suffolk Lodge provides accommodation and care for up to 40 service users over the age of 65, who have care needs associated with old age. The home has a dementia care unit (Ash unit), providing accommodation for 7 service users. Suffolk Lodge is a purpose built property located close to Wokingham town centre, with accommodation on the ground and first floor. The home is split into units. Each unit has a kitchen/lounge/dining area and single bedrooms, there is also a toilet and bathroom in each unit. There is in addition a large communal lounge located on the ground floor. There is a lift to access the first floor. Fees are £510 for private residents. DS0000031244.V325366.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced site visit which took place during the day on the 23rd January 2007. The pre-inspection questionnaire, seven service users’ questionnaires and one GP comment card were returned to the inspector before the site visit. These, together with the site visit, were the main sources of information for the key inspection. During the site visit the inspector spoke with four service users; interviewed the two assistant managers; spoke with a residential care officer and two care assistants; toured the premises; looked at records; case tracked; and observed the interaction between service users and staff. Twenty-one standards were assessed during the site visit of which nineteen were met and two were nearly met. One requirement and two recommendations were made. What the service does well: What has improved since the last inspection? What they could do better: Regulation 26 visits to take place every month and the care plans are reviewed every month and recorded. DS0000031244.V325366.R01.S.doc Version 5.2 Page 6 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. DS0000031244.V325366.R01.S.doc Version 5.2 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 DS0000031244.V325366.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Number 3. Quality in this outcome area is good. New service users are admitted only on the basis of a full assessment being undertaken. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Files of recently admitted service users showed comprehensive pre admission assessments were undertaken. DS0000031244.V325366.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Numbers 7, 8, 9 and 10. Quality in this outcome area is good. Service user’s health, personal and social care needs are set out in detailed and comprehensive individual plans of care. Service user’s plan are reviewed but not as regularly as they should be. Service users’ health and personal care needs are well met. Staff adhere to the medication policies and procedures. Service users feel they are treated with respect and dignity. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service user files looked at contained detailed individual plans. The plans are reviewed once a year with the social services care manager, relatives and the service user. Service users’ needs are reviewed at ‘hand over’ meetings and the plans updated whenever there is a change in the service user’s care needs. The service user’s plan should be reviewed by care staff at least once a month and recorded. In response to the question in the service user questionnaire ‘do you receive the medical support you need?’ five service users replied ‘always’ and two DS0000031244.V325366.R01.S.doc Version 5.2 Page 10 ‘usually’. The GP, in his comment card, said the service users’ personal and health care was good. Records showed service users see appropriate health professionals when required and have their weight checked regularly. Files contained records to monitor areas of health such as incontinence, food and liquid intake and pressure sores when required. A member of staff runs a ‘gentle exercise’ session once a week. The administration of medication records was in order. No service user self medicates. A pharmacist last visited the home to inspect the medication procedures in March 2006. A pharmacist is due to visit the home in the next few days. The inspector recommended the visits take place three to four times a year. In the service user questionnaire, five service users replied, ‘always’ and two ‘usually’ to the question ‘do you receive the care and support you need?’ and all replied ‘always’ to the question ‘do the staff listen and act on what you say?’ Service users said ‘staff are generally caring and obliging’, ‘you can get up and go to bed when you like’, ‘staff are kind and listen to you’ and ‘I have no complaints about the care I receive’. Staff were observed to be attentive, caring, respectful and spent time talking to service users. Service users looked clean and presentable. DS0000031244.V325366.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Numbers 12, 13, 14 and 15. Quality in this outcome area is good. Service users have their social, cultural, religious and recreational interests and needs well met. Service users maintain contact with family, friends and the local community. Service users are helped to exercise choice over their lives. Service users enjoy their meals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: An activity organiser is usually employed to provide a wide range of enjoyable and stimulating activities for the service users. This post is currently vacant and a member of the management team is arranging activities. Service users said, ‘there are sufficient activities’. Three of the service users’ questionnaires returned said there are always activities arranged by the home that they can take part in and four said usually. One commented that ‘staff always ask if I want to join in’. Special days of the year, religious festivals that reflect the different cultural backgrounds and birthdays are celebrated. One service user attends a day centre in the community, several service users attend Church services in the community, and service users are taken out for DS0000031244.V325366.R01.S.doc Version 5.2 Page 12 day trips and to events in the community. Service users said friends and relatives are always made welcome. Service users can handle their own financial affairs if they wish. Service users can bring personal possessions with them and have access to personal records. Service users said they have choice about what they do. Records of staff meetings showed the manager reinforced the importance of service users having choice in their lives. Service users said they like the food and they have a choice at meal times. Five service users who returned the questionnaire said they always liked the meals; and two said usually. The menu showed a wholesome and nutritious diet was offered to the service users. Service users have their meals in their own units. The main meal of the day is cooked in the main kitchen. The other meals are cooked and prepared in the units. Meal times are not rushed and dietary and cultural needs are catered for. Service users help to lay and clear the tables. DS0000031244.V325366.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Numbers 16 and 18. Quality in this outcome area is good. Service users are confident that their complaints will be listened to, taken seriously and acted upon. Service users are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints procedure. Leaflets on how to make a complaint are given to service users and their relatives. No complaints have been made to the home or the Commission since the last inspection. All the service users who returned the surveys said they know how to make a complaint; four said they know who to speak to if they are not happy and three said usually. Service users interviewed said ‘staff listen to them if they have a problem’. The home has a vulnerable adults procedure (including whistle blowing). Accidents to service users are recorded. The majority of staff have either had or been booked to attend POVA training. The Commission has received no allegations of abuse since the last inspection. DS0000031244.V325366.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Numbers 19 and 26. Quality in this outcome area is good. Service users live in a safe, well maintained, clean and hygienic environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is safe, adequately maintained, and provides a comfortable and pleasant environment for the service users. Since the last inspection four of the five units have had new units installed in the kitchen areas; the lounge and bedrooms in Cedar unit have been decorated and had new carpets fitted; the main corridor in the home has had a new carpet fitted; and Oak unit is in the process of being decorated and having new carpets fitted. It is planned to have Elm unit refurbished next. On the day of the site visit the home was clean and hygienic. Service users said the home is always fresh and clean. Three service users who returned their questionnaires said the home is always fresh and clean and four said usually. DS0000031244.V325366.R01.S.doc Version 5.2 Page 15 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): Numbers 27, 28, 29 and 30. Quality in this outcome area is good. Service users needs are met by the numbers and skill mix of the staff. 28 of staff have achieved a NVQ 2 or above in care. The home operates a thorough recruitment procedure. Staff are trained and competent to do their jobs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home employs a manager, Two assistant managers, three residential care officers, one team support officer, twenty six care assistants, a driver/gardener/handyman, a cook, four domestics, a laundry assistant and six relief care assistants. The activity officer and two care assistant posts are vacant. Regular agency staff, relief staff and staff undertaking overtime cover the vacant care hours. The duty rota showed there were sufficient staff on duty to respond satisfactorily to the service users’ needs. Service users said, ‘staff are nice’, there are sufficient staff’ and ‘staff come promptly’. Service users who returned their questionnaires said,’ I’m quite happy’, ‘I’ve got no complaints’ and ‘I will give full marks to this place’. In reply to the question, ‘are the staff available when you need them’, three replied always, three replied usually and one replied sometimes. Comments included, ‘it depends what time they start, and ‘when they are short of staff it is difficult’. Staff interviewed demonstrated a good understanding of the conditions and needs of the service users and said ‘they were happy working in the home’ and ‘there is sufficient time to interact with the service users’. DS0000031244.V325366.R01.S.doc Version 5.2 Page 16 28 of the care staff have a NVQ2 or above in care Staff records showed appropriate recruitment procedures are followed. Records showed the home offers a comprehensive training programme including refresher training. New staff receive induction training and training in core areas of their work. Staff also attend courses on topics such as dementia, bereavement, screening for malnutrition and diversity to gain a better understanding of the service users’ needs and conditions. Staff said ‘the training offered was good’. DS0000031244.V325366.R01.S.doc Version 5.2 Page 17 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): Numbers 31, 33, 35 and 38. Quality in this outcome area is good. The registered manager is qualified and competent to run the home and meet its stated purpose, aims and objectives. The home is run in the best interests of service users, but Regulation 26 visits need to take place every month. Service users’ financial interests are safeguarded. The health, safety and welfare of service users and staff are promoted and protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager has been in post for several years and has completed all the necessary qualifications in relation to this post. Staff described the manager as being clear in how she wants the home to run, supportive, and good in her role. DS0000031244.V325366.R01.S.doc Version 5.2 Page 18 Service users complete satisfaction questionnaires every year. A summary of their responses is produced. An annual business/development plan is completed every year. The management team are consulting with relatives, GPs and other professionals to produce a suitable questionnaire that can be sent to them every year to gain their views about the quality if care in the home. Staff meetings take place at regular intervals. Service user meetings take place on the units. Relatives are invited when they take place on the EMI unit. Only four Regulation 26 visits took place last year. A health and safety audit of the premises takes place every year. Relatives or power of attorneys handle the finances of service users. Service users’ personal money is held in one bank account and two signatures are required to withdraw money for service users’ use. Each service users has a “residents cash account sheet”. Records and receipts are kept of all transactions. The team support officer on a weekly basis, checks the records, bank account and service users cash on site by completing clear reconciliations to safeguard service users monies and check the administration procedures. Copies of individual record sheets are sent to the finance department who further check and send copies to appropriate service users next of kin/power of attorneys. One service user manages her own personal money after it is withdrawn from the bank. She has a lockable facility in her room. Records showed all the necessary Health and Safety checks and inspections have taken place. Records showed all the service users have had appropriate risk assessments undertaken. DS0000031244.V325366.R01.S.doc Version 5.2 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 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 X 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 2 X 3 X X 3 DS0000031244.V325366.R01.S.doc Version 5.2 Page 20 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 OP33 Regulation 26 Requirement The registered provider or a company representative must visit the home on a once monthly basis in accordance with Regulation 26. Timescale for action 28/02/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP7 OP9 Good Practice Recommendations The service user’s plan is reviewed by care staff at least once a month and recorded. Ensure a pharmacist visits at least 3-4 times a year to inspect the receipt, storage, recording, administration and disposal of the medication. DS0000031244.V325366.R01.S.doc Version 5.2 Page 21 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 DS0000031244.V325366.R01.S.doc Version 5.2 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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