Inspection on 28/09/05 for Sutton Court Lodge

This inspection was carried out on 28th September 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Sutton Court Lodge 31/01/08

Sutton Court Lodge 22/01/07

Sutton Court Lodge 30/01/06

Sutton Court Lodge 17/02/05

Sutton Court Lodge 06/09/04

Sutton Court Lodge 17/03/04

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Hillside

Applegarth

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Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOMES FOR OLDER PEOPLE Sutton Court Lodge 2 Chesterfield Road Brimington Chesterfield Derbyshire S43 1AD Lead Inspector Jill Wells Unannounced Inspection 28th September 2005 10:00a 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 Sutton Court Lodge DS0000020101.V255238.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Sutton Court Lodge DS0000020101.V255238.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Sutton Court Lodge Address 2 Chesterfield Road Brimington Chesterfield Derbyshire S43 1AD (01246) 275703 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) Derbyshire Care & Home Support Limited Mrs Patricia Ann Page Care Home 9 Category(ies) of Learning disability over 65 years of age (9) registration, with number of places Sutton Court Lodge DS0000020101.V255238.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the home be reigstered for one named service user under 65. Date of last inspection 17th February 2005 Brief Description of the Service: Sutton Court Lodge is registered to provide 9 places for residents over 65 with learning disabilities. The home is presently able to accommodate one name service user under 65. The home is a detached house in Brimington, which provides 5 single and two shared rooms. At the time of the inspection no residents were sharing a room.the home news on two floors and has a stair lift to support residents that have difficulty with the stairs. The home is maintained to a clean, comfortable and homely standard. the home is in the centre of Brimington Village close to shops and transport facilities. There are two bathrooms and three toilets, with appropriate grab rails in place to assist residents. There is a communal lounge and separate dining room area for residents to use. There is a loop system fitted in the lounge area for residents with a hearing aid . Sutton Court Lodge DS0000020101.V255238.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection visit was unannounced and took place over a 3.5 hour period. During visits the inspector spoke with four residents and three staff working at the home. The tour of the building took place, as well as inspecting records, which included residents files. What the service does well: What has improved since the last inspection? What they could do better: Although residents were encouraged to be as independent as they were able, there were not always risk assessments in place for individuals. Although a written risk assessments had identified a high risk concerning radiators in specific areas not being covered, covering of radiators still had not taken place, which was of concern. Although it was evident that the manager and staff team were experienced, there seemed a reluctance to undertake the required NVQ qualifications. Issues highlighted by a pharmacist at a recent inspection included inadequate storage space for medicines. Several staff had been off sick for some time and this had placed a strain on the staff team. It had also reduced the potential for the social needs of residents to be met. Sutton Court Lodge DS0000020101.V255238.R01.S.doc Version 5.0 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. Sutton Court Lodge DS0000020101.V255238.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sutton Court Lodge DS0000020101.V255238.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,5. Although the required documents were in place, they did not give prospective residents the information they needed to make an informed choice about where to live. EVIDENCE: There was a statement of purpose available at the home. The statement of purpose states that Catriona Bradley is the registered manager, which is incorrect as Mrs Patricia Page is actually the registered manager for Sutton Court Lodge. The statement of purpose was a very general document concerning Derbyshire Care and Home Support (DCHS) and was not specific to the care home. The statement of purpose did not set out the physical enviromrnt standards met by the home in relation to the relevant standards. There was a service user guide available. Again this document was not specific to Sutton Court Lodge. It stated that fees were calculated on a fixed hourly rate basis, which was not the case, and also referred to a domiciliary agency. The telephone number on the service user guide for CSCI was not accurate. Staff on duty on the day of the inspection were not aware of an alternative service user guide in more appropriate formats for residents. Sutton Court Lodge DS0000020101.V255238.R01.S.doc Version 5.0 Page 9 There had recently been a new resident admitted to the home. This resident had the opportunity to visit the home before they made decision whether to live there. There was a statement of terms and conditions in an alternative formats for residents. Not all of these have been signed and dated either by the residents, their representatives or a representative from the home. Sutton Court Lodge DS0000020101.V255238.R01.S.doc Version 5.0 Page 10 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): 7,8,9,11. The health and personal care needs of residents were met within the home with support from outside health professionals where relevant. EVIDENCE: Each resident had a service user plan in place. This included a personal profile, and daily records, with any significant information recorded. Residents also had a medical diary stating any health appointments that had been organised. Although residents weight was monitored,there was not nutritional screening undertaken. Information was available concerning preferences around personal care. Staff completed a monthly evaluation for each resident, recording any significant issues for the previous month. Residents had a personal planning book which they worked on themselves. This book was in a format appropriate to the resident. This information recorded information about them as individuals. There was a key worker system at the home. Individual records showed that residents had access to health care professionals including visits to the GP, hospital appointments, dentist, opticians and chiropody. Staff would support them during these appointments. Sutton Court Lodge DS0000020101.V255238.R01.S.doc Version 5.0 Page 11 Medication administration records were inspected. They were generally in good order.However staff need to ensure that when there is an optional dose, the dose given must be recorded. There had been a pharmacist visit the previous day to the inspection. This had highlighted that the storage cupboard for medication was not big enough for the quantity of medication stored. There was a system for safe returns of medication. The pharmacist had identified gaps in the medication administration records where there was not an initial or code. There was not a separate lockable medication fridge for medication that required refrigeration. It was stated that the kitchen fridge was used for this, which was not ideal. However they were no medication that required refrigeration at the time of the inspection. Although the pharmacist had stated that medicines were stored correctly, the cupboard where the locked medicine cupboard was placed inside, stored other items. This included master keys for every lock within the home. This cupboard was not locked. Residents individual records showed that discussions have taken place concerning the residents understanding and experience of death, and included their wishes after death. The records also included residents religious beliefs. Sutton Court Lodge DS0000020101.V255238.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 14, 15. Residents were offered the opportunity to be active, and have a level of privacy and independence, as they preferred. EVIDENCE: Most residents attended a day centre. One resident was supported to attend a day centre that they previously attended before they came to live at the home. Most residents are over 65, several being in their 70s and 80’s. One resident spoken to said that they did not do very much and this is how they liked it. The home had a lease car used to take residents out. Several residents had mobility allowance and would use this to pay for taxis.There was easy access to local transport and some residents regularly used public transport. Residents were encouraged to maintain family links and friendships both inside and outside the home and visitors were welcome. Several residents had friends living in other homes and staff supported them to keep up these friendships by visiting them. There was evidence that residents wishing to have intimate personal relationships were offered guidance and help to make appropriate decisions. Resident spoken to said that the food at the home was very good. Residents were encouraged to shop for food with a member of staff. It was evident from observations that mealtimes were relaxed, unrushed and in a pleasant Sutton Court Lodge DS0000020101.V255238.R01.S.doc Version 5.0 Page 13 environment. One resident required food cutting up and staff were aware of this need. Records were kept of food provided. Staff respected resident rights to make decisions about their own life and assisted them to do so. An example was a resident that had recently chosen how to have their room decorated, choosing their own carpets and curtains. Staff enable residents to take responsible risks, for example two residents went out without support from staff. Although there were some risk assessments in place, these did not include a risk assessment concerning outings without support from staff, and resident use of the stair lift without assistance. Some residents were able to bathe without support from staff, however risk assessments were not in place. Sutton Court Lodge DS0000020101.V255238.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 There were systems in place for encourage residents to make suggestions and complaints. EVIDENCE: There was a complaints procedure available in an appropriate format for residents. This explains how they could complain. However the written complaints procedure had the wrong telephone number of CSCI. It was stated that there had been no complaints since the last inspection. There were written procedures for responding to suspicion or evidence of abuse (including Whistle blowing) there was also a written policy and procedure concerning referral and checks of the protection of vulnerable adults (POVA) register. Some but not all staff had undertaken adult protection training. The homes policies and practices regarding service users money and financial affairs were not inspected on this occasion. Sutton Court Lodge DS0000020101.V255238.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,24,25,26. There was a well maintained environment with comfortable communal facilities. EVIDENCE: The premises were accessible, safe and well maintained. The home was on two floors which was not ideal for residents over 65, however there was a stair lift in place that was used by two residents. The home was bright, airy, clean and free from offensive odours. There was sufficient and suitable light, heat and ventilation. There were no residents that needed to use a wheelchair within the home. Furnishings were of a good quality and domestic in character. Staff stated that maintenance and renewal was generally undertaken quickly. The home had recently been re decorated to a good standard. There was a communal lounge and separate dining area. There was a loop system fitted in the lounge area to assist residents with a hearing aid. There were two bathrooms and three toilet facilities with grab rails in place to assist residents. One of the bathing facilities was suitable for residents with Sutton Court Lodge DS0000020101.V255238.R01.S.doc Version 5.0 Page 16 mobility difficulties. One handrail in the first floor toilet had the plastic coating peeling off. There were wash basins in bedrooms. Bedrooms were comfortable and personalised, well furnished and equipped. Laundry facilities were sited away from where food was stored and cooked. There was an industrial washing machine and dryer. The washing machine had a sluicing facility. C.O.S.H.H. materials were stored in a lockable cupboard within the laundry area, however at the time of the inspection this cupboard was not locked. It was advised that locking the laundry door would minimise any potential risks. Sutton Court Lodge DS0000020101.V255238.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28. The staffing levels did not always meet the needs of residents. EVIDENCE: On the day of the inspection there were three support staff on duty. It was stated that this was unusual. During the day there was generally two staff on duty and one waking night staff. There had been staff off sick on a long-term basis for some time and it was evident that this was having an effect on both staff and residents. Staff were working additional hours on a regular basis to cover the gaps in the rota. It was explained that although the home has not gone under the minimum staffing hours, there was infrequently sufficient staff on duty to take residents out. It was stated that several residents enjoyed visiting the church on Sunday, however this was infrequently done due to staff shortages. There were 17 staff working at the home. One worker had completed NVQ 3 Care, one worker had started NVQ 2 Care and two staff were registered to start the course. The requirement was for 50 of care staff to have undertaken NVQ 2 Care by Dec 2005. Sutton Court Lodge DS0000020101.V255238.R01.S.doc Version 5.0 Page 18 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): 31,38. The manager of the home was experienced within her role. The there were generally safe systems in place for the health, safety and welfare of service users, although specific issues required attention. EVIDENCE: The manager was not present during the inspection however from discussions with residents and staff it was evident that the manager was well liked, competent and experienced within her role. The staff believed that the manager had not started the required the NVQ 4 Management qualification, although she was a qualified nurse. There were generally safe working practices taking place. It was stated that there was no moving and handling support required. Protective gloves were available for staff use. Sutton Court Lodge DS0000020101.V255238.R01.S.doc Version 5.0 Page 19 Record showed that there was a safe system for fire safety. Water temperatures from bath taps were regulated close to 43°C for safety. Window restrictors were in place. The manager had undertaken written risk assessments concerning the environment. This had included risk assessments concerning the covering of radiators in toilets, bathrooms and bedrooms. The written risk assessments had highlighted that this was required, however radiators were still left uncovered in areas where residents may be vulnerable. Communal soap and towels were used in toilet and bathroom areas. This was not ideal as this practice did not minimise the risk of cross infection. There was a central heating boiler in the downstairs toilet. It was stated that staff and residents have occasionally bumped their head on this boiler due to the positioning of the boiler and the need to reach around for the towel. At the time of the inspection this boiler was very hot to the touch. Sutton Court Lodge DS0000020101.V255238.R01.S.doc Version 5.0 Page 20 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 3 x x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 3 3 3 3 2 x 3 3 2 STAFFING Standard No Score 27 2 28 2 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x x x x x x 2 Sutton Court Lodge DS0000020101.V255238.R01.S.doc Version 5.0 Page 21 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. one 1 2 Standard OP1 4 and 5 OP9 13(2) Regulation Requirement Timescale for action 30/12/05 3 4 OP9 OP9 13(2) 13 (2) 5 OP9 13 (2) 6 OP12 13 ( 4) 7 OP16 22 (6) (a) The statement of purpose and service user guide must be revised. Where medication 28/09/05 administration records states an optional dose there must be a record of the dose actually given. There must be adequate 30/11/05 storage for all medicines. The main medication cupboard 30/09/05 must be locked to ensure safety of items within the cupboard including keys, as well as added security for medication. When residents are prescribed 30/12/05 medication that requires refrigeration, there must b a lockable fridge specifically for this purpose. There must be relevant 30/11/05 individual risk assessments in place. This must include a risk assessment concerning outings without staff support, bathing alone, and use of the stair lift unassisted. The complaints procedure must 30/10/05 be amended to ensure that the correct telephone number of the DS0000020101.V255238.R01.S.doc Version 5.0 Page 22 Sutton Court Lodge 8 OP22 23 9 OP26 13 10 OP28 18(1)(c) (i) 18 11 OP27 12 OP31 9 13 OP38 13(4) Commission for Social Care Inspection is on the document. The handrail in the first floor bathroom that had the plastic coating peeling off must be replaced. C.O.S.H.H. materials stored in the laundry area must be secure at all times. The registered manager should consider keeping the laundry door locked to minimise risk. There must be 50 care staff that have undertaken or have started the NVQ 2 Care qualification by December 2005. There must be adequate staff on duty to meet the needs of service users including social needs. This may need a review of how staff hours are used. The registered manager must have a qualification, or have started the qualification at least level 4 NVQ in Management or equivalent . Radiators must be made safe in areas where residents may be vulnerable. 30/11/05 28/09/05 31/12/05 31/10/05 31/12/05 30/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP8 OP38 OP38 Good Practice Recommendations Nutritional screening should be undertaken for each resident. The registered manager should consider the use of an alternative to communal soap bars and towels in toilet areas to minimise the risk of cross infection. The registered manager should undertake a written risk assessment concerning the central heating boiler in the DS0000020101.V255238.R01.S.doc Version 5.0 Page 23 Sutton Court Lodge downstairs toilet where staff and residents have bumped themselves, also taking into account the hot surface. Any action identified on the risk assessments must be met. Sutton Court Lodge DS0000020101.V255238.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Sutton Court Lodge DS0000020101.V255238.R01.S.doc Version 5.0 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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