Inspection on 19/05/05 for Terrington Lodge

This inspection was carried out on 19th May 2005.

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

Terrington Lodge 17/03/09

Terrington Lodge 20/02/07

Terrington Lodge 14/07/05

Terrington Lodge 14/12/04

Terrington Lodge 08/06/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Terrington Lodge Lynn Road Terrington St Clements Norfolk PE34 4JX Lead Inspector Chris Handley Unannounced 19 May 2005 10.00am 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 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. Terrington Lodge I55 S39909 Terrington Lodge V227275 190505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Terrington Lodge Address Lynn Road Terrington St Clements Norfolk PE34 4JX 01553 829605 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Jaswant Singh Beeharry Mrs Isabel Beeharry Miss Lisa Farr Care Home 25 Category(ies) of Old Age (25) registration, with number of places Terrington Lodge I55 S39909 Terrington Lodge V227275 190505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: The home may admit one service user who is under 65 years of age, who will be named in the Commissions records, until 28th February 2006. Date of last inspection 14 December 2004 Brief Description of the Service: Terrington Lodge is a residential care home registered to provide care for 25 elderly people. The home is a detached building of traditional design which has had a large wing added. There are 19 single rooms, and 3 double rooms. There is a large lawn at the rear of the home, and a car park at the front of the home. There is an ornamental fountain in the front garden and a number of large mature trees. The Registered Proprietors are Mr & Mrs Beharry, and the Registered Manager is Miss L Farr. The home situated in the village of Terrington St Clements, which is approximately ten miles from Kings Lynn. Terrington Lodge I55 S39909 Terrington Lodge V227275 190505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and was carried out as part of the annual programme. During the inspection 6 residents, and 3 visitors were interviewed by the Inspector as well as 5 members of staff. The Inspector toured the home accompanied by the Manager who introduced him to the residents. As part of this inspection 21 Standards were inspected and a wide range of documentation was examined. The Inspector was accompanied by the Manager and Proprietors throughout the day. What the service does well: What has improved since the last inspection? All the radiators and hot water pipes which presented a potential danger to residents, have been protected. The training has increased since the last inspection. Terrington Lodge I55 S39909 Terrington Lodge V227275 190505 Stage 4.doc Version 1.30 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Terrington Lodge I55 S39909 Terrington Lodge V227275 190505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Terrington Lodge I55 S39909 Terrington Lodge V227275 190505 Stage 4.doc Version 1.30 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 standard(s) 2,&5, All residents are supplied with detailed Terms and Conditions. Prospective residents and relatives are welcomed to visit the home prior to admission. EVIDENCE: All residents/relatives are supplied with Terms and Conditions, the Manager said. A copy was seen. These are well set out documents, and are in a readable print size. They are signed by the residents or a relative on their behalf. A copy is provided to the resident, or relative as the case may be. Signed copy is kept in the office. Terrington Lodge I55 S39909 Terrington Lodge V227275 190505 Stage 4.doc Version 1.30 Page 9 Pre-admission visits, are positively welcomed. Prospective residents and relatives, are taken on a tour of the home, they view the room which it is intended to use, talk to staff, and other residents, and are provided with information about the home. During the process of the inspection a relative of a prospective residents visited the home for this purpose, and was met by one of the Proprietors, who offered the visitor the opportunity to meet the Inspector if she so wished, but the offer was declined. One resident interviewed said that he had visited the home before he came, and though he knew the home, the visit had been a big help to him, in that it provided him with a good picture of how the home functioned. Terrington Lodge I55 S39909 Terrington Lodge V227275 190505 Stage 4.doc Version 1.30 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 standard(s) 7,8,9,&10 The home is not yet in a position to be sure that they are meeting all the needs of service users as they do not appear to look at social needs nor is there evidence that they are involving the service user and/or their relatives in the process. EVIDENCE: All residents have an individual care plan, which ensures that health care needs of residents are assessed, a plan of remedial action is planned, implemented and reviewed. Three sets of care plans were read in detail. The documents are clearly marked “Private and Confidential”. The home undertakes pre-admission assessments and it is recommended that the document used be clearly headed Pre-admission Assessment. There are a series of a assessments undertaken and recorded, including physical and mental health. Risk Assessment is carried out. In the notes seen there was no assessment of social needs/abilities. Care is reviewed on a monthly basis but there was no evidence of the resident/and relative being involved in reviews of care. See Recommendations. A daily record is maintained and brief succinct records were read. These records are clearly written. Terrington Lodge I55 S39909 Terrington Lodge V227275 190505 Stage 4.doc Version 1.30 Page 11 The staff of the home provide a wide range of personal care for residents, and residents said that they always did this very well. All residents have a G.P. and should a resident have any health care needs, they would be referred to the appropriate department via the G.P. There is one resident who has a pressure sore which is being treated by the District Nurse. The pressure sore is getting better slowly. The Inspector met the District Nurse briefly. Chiropody and Dental services are arranged for residents. The home uses Boots Monitored Dosage System. The medicines are kept in a locked trolley, which is kept locked to the wall. There is a Controlled Drug Cupboard in place, and a drug which has to be kept as a Controlled Drug was counted and found to be correct against the Register. Staff who administer medicines have received training for this. There are no residents who self medicate. The records of administration are clearly and neatly recorded. The Home has a comprehensive, well set out procedure for all aspects of medicines in the home. The home enjoys a good working relationship with the supplying pharmacist. If staff had any concerns about the effect of medicines they would contact the prescribing G.P. Privacy forms part of the induction of staff, both the importance of it, and the providing it in the daily life of residents. During the process of the inspection knocking on doors prior to entry was seen several times. Residents said that the staff always knock prior to entry, and that privacy is always provided, especially if they were being provided with personal care. There is easy access to the public phone. Any consultation or examination would be carried out in the privacy of the residents room. There are privacy screens in double rooms. Terrington Lodge I55 S39909 Terrington Lodge V227275 190505 Stage 4.doc Version 1.30 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 standard(s) 15 The home provides good catering services. EVIDENCE: The menus seen appear varied, nutritious, and interesting. Special diets are recorded. The residents spoke very well of the catering services. Residents were discreetly observed taking their mid day meal with obvious enjoyment. There is choice and the likes and preferences of the residents are know to the catering staff. Birthdays and special events are celebrated. There are 5 residents who require a diabetic diet, and one resident requires a high potassium diet. Staff are clearly aware of the importance of catering in the daily life of the resident, judging by their attention to individual likes and small details. Terrington Lodge I55 S39909 Terrington Lodge V227275 190505 Stage 4.doc Version 1.30 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,17,&18. The home has a complaints procedure which it known to both residents and staff. The legal rights of residents are protected. The home has an Adult Protection Policy which is known to staff. EVIDENCE: The home’s complaints procedure is posted up around the home. Staff interviewed knew how a complaint could be made, and they knew what to do if a residents told them that they wanted to make a complaint. Staff are aware that they have an important role to play in this matter. Residents interviewed knew what to do if they had a complaint to make, and added that they would just go and see a member of staff who would “sort it out”. Residents have their legal rights protected and the Proprietors and Manager would facilitate access to advocacy services if required. Some residents chose to use their postal vote in the recent elections. The home has an Adult Abuse Protection procedure, which was seen, the document is well set out. Training has been provided for staff to raise their awareness in this matter. Staff interviewed knew what steps to take if they suspected that such an incident took place, and they also recognised that this may not be openly obvious. Terrington Lodge I55 S39909 Terrington Lodge V227275 190505 Stage 4.doc Version 1.30 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,24,25,&26. The location and layout of the home is suitable for its purpose. The residents’ rooms are decorated, and maintained to a good standard. The accommodation meets the needs of the residents and the environmental health department. The premises were neat, clean and free from offensive odours. EVIDENCE: The home is suitable for stated purpose. The home has a programme of routine maintenance, which was seen. This ensures that maintenance of the property is carried out on an on going basis. The grounds are well maintained, there is a large car park, which is adjacent to the front door. There is an ornamental fountain in the middle of this car park. There is a well kept lawn at the rear of the home, which is accessible for residents, and provide a quiet sitting out area. Terrington Lodge I55 S39909 Terrington Lodge V227275 190505 Stage 4.doc Version 1.30 Page 15 The building complies with the requirements of the local fire service and environmental health department. The Inspector undertook a tour of the home accompanied by the Manager and most of the rooms were seen. The rooms seen were all neat and tidy. They are comfortably furnished, and have items of furniture, pictures and photographs, belonging to the resident. The rooms give the appearance of having being personalised by the resident. The residents spoke highly of their rooms and said so to the Inspector. Residents in this home have been asked if they want locks on the doors of their rooms, and have declined to have them fitted. All the residents interviewed requested the Inspector to leave the door of their room open so that they “could see what was going on” when the Inspector left their room. All the rooms have views out over the gardens. There are screens provided in double rooms, and the Inspector recommends that these be replace with privacy curtains which would be safer for residents to use, in that they would be less likely to stumble over them. The heating, lighting, water supply, and ventilation of resident’s rooms meet the environmental health the safety requirements. The rooms are individually and naturally ventilated. Rooms are centrally heated and the heating can be controlled by the resident. There is emergency lighting throughout the home which is tested on a 6 monthly basis. Water is stored at least 60oC. and distributed at 50oC. There are preset valves in place which have fail devices fitted, to provide water close to 43oC. All the hot water pipe work has now been covered, the Manager said, thus protecting the residents from burns or scalds. The Inspector visited the laundry accompanied by the Manager. The laundry is sited so that soiled linen is not taken through areas where there is food. There is good natural light in the laundry room. There are hand washing facilities in place. The laundry floor is impermeable. There are polices and procedure for the control of infection, and the safe handling and disposal of clinical waste, dealing with spillages and the provision of protective clothing. The washing machines have specified programmes to meet disinfection standards. The services and facilities comply with the Water Supply (Water fittings) Regulations. The Inspector spoke briefly to a member of staff working in the laundry. Terrington Lodge I55 S39909 Terrington Lodge V227275 190505 Stage 4.doc Version 1.30 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 28 & 29, The home has an NVQ training programme. The home has effective recruitment documentation and practice. EVIDENCE: The Manager said that there were two members of staff who had NVQ II, and 5 members of staff were taking NVQ II. There are a further 3 who will be enrolling under the modern apprenticeship scheme, in the near future. There is one member of staff who has NVQ III, and two others who are just finishing NVQIII. The home has done well in this matter and when all the present training is complete it will mean that there are 50 of staff who have NVQ training. This level of training will enhance the safety and quality of care provided to residents. All the staff who have undertaken this training are warmly commended. One member of staff said that when she first commenced this training she had found it difficult but as things moved along she found that it made more sense and that it had become a little easier, and that it had improved her confidence. This level of training will enhance the safety and quality of care provided to residents, and will also develop the confidence and skills of staff. Terrington Lodge I55 S39909 Terrington Lodge V227275 190505 Stage 4.doc Version 1.30 Page 17 The home has a well set out recruitment and selection procedure which was seen. It is comprehensive and detailed. It is based on equal opportunities and ensures the protection of residents, as far as is possible. Posts are advertised, application forms are required to be completed, two written references are obtained, Police and POVA checks are carried out. Interviews are well prepared for, and carried out by the Manager and another senior member of staff. Job descriptions, and terms and conditions are provided. Staff are provided with copies of the Code of Conduct and Practice as set by the GSCC. The home does not use volunteers. The home’s practice in this matter enhances the safety of residents in particular, and the home in general. Terrington Lodge I55 S39909 Terrington Lodge V227275 190505 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,33,34,36,&37 The Manager is qualified, competent, and experienced to run the home. The management of the home is not yet in a position to say that the home is run in the best interests of the service users as they have not collated the results of their survey. Staff supervision takes place and is recorded. The home has records required by legislation. EVIDENCE: The Manager has been working in the home for 14 years, she is currently in the final stages of taking her NVQ 4. She has undertaken a wide range of training including, Advanced Management of Care, First Aid, Food Hygiene, Adult Abuse Awareness, Moving and Handling, Continence Care, and Nutrition. Terrington Lodge I55 S39909 Terrington Lodge V227275 190505 Stage 4.doc Version 1.30 Page 19 The Manager and senior staff are familiar with the conditions and disease associated with old age. There are clear lines of accountability from the Manager directly to the Proprietors. She is the Manager of this home only. The Manager has a comprehensive and well set out job description, which was seen. The Manager monitors the services provided on a regular basis, by going round the home to view the premises, observing staff, and talking with residents. The home has undertaken a survey of the services which it provides, but as yet has not collated this. When the work with the survey has been completed it is intended to pursue developing Quality Assurance in the home. The Manager has made initial contacts in this matter. The appropriate Insurance documentation was seen by the Inspector, it is displayed on the wall adjacent to the front door. Records of transactions are kept by the Proprietors and were seen. Business and financial plans dated 5/4/05 were seen by the Inspector, and they showed the business to be financially viable. The Manager undertakes and records staff supervision. The supervision covers all aspects of practice, the philosophy of the home, and career development needs. The records kept identify training needs and form the basis of the training plan for staff for the next year. During the process of this inspection a wide range of records required by legislation were seen and examined. The documents are of a high standard, they are comprehensive and well set out. Many of these documents have been developed by the Manager, and she is commended for this. Records are kept secure and only authorised persons including the residents have access to them. Terrington Lodge I55 S39909 Terrington Lodge V227275 190505 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 x x 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 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x 3 3 3 STAFFING Standard No Score 27 x 28 3 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 x 2 3 x 3 3 x Terrington Lodge I55 S39909 Terrington Lodge V227275 190505 Stage 4.doc Version 1.30 Page 21 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard Regulation None 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. 1. 2. 3. 4. 5. Refer to Standard 7 7 7 25 33 Good Practice Recommendations That the preadmission assessment document be marked Pre-admission Assessment and Private and Confidential. That there is an assessment of social skills/interests made and recorded. That the presence of residents/relatives at reviews of care should be recorded. That privacy screens should be replaced with privacy curtains. That the home take steps to collate their surveys into a plan for improvement of the home, which is submitted to the Commission. Terrington Lodge I55 S39909 Terrington Lodge V227275 190505 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection 3rd Floor Cavell House St Crispins Road Norwich NR3 1YF 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 Terrington Lodge I55 S39909 Terrington Lodge V227275 190505 Stage 4.doc Version 1.30 Page 23 - 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. 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