Inspection on 01/11/06 for The Lodge

This inspection was carried out on 1st November 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Lodge 29/10/07

The Lodge 16/02/06

The Lodge 06/10/05

The Lodge 21/01/05

The Lodge 14/10/04

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

CARE HOMES FOR OLDER PEOPLE The Lodge Copdock Ipswich Suffolk IP8 3JD Lead Inspector Jane Higham Unannounced Inspection 1st November 2006 10:05 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 The Lodge DS0000024437.V317341.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. The Lodge DS0000024437.V317341.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Lodge Address Copdock Ipswich Suffolk IP8 3JD 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) 01473 730245 T/F 01473 730245 mick@geminicarelodge.orangehome.co.uk Gemini Care Limited Mr Michael Bailey Care Home 44 Category(ies) of Dementia - over 65 years of age (44) registration, with number of places The Lodge DS0000024437.V317341.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th February 2006 Brief Description of the Service: There has been a residential home caring for older people in the present building for many years. The current owner, Gemini Care Homes Ltd (a company owned wholly by Mr Abbas), was registered in December 1997. The Home is a large country house set in its own mature gardens, situated on the main road running through the village of Copdock. The County Town of Ipswich is a few miles to the north and the home is near to the main A12 road from London. The current owner carried out an extensive refurbishment of the accommodation in 1998, and in late 2005 completed two new ground floor wings providing spacious accommodation to a very high standard. At the same time a further refurbishment, and expansion of the communal areas was carried out, with more separate communal areas being created, and at the same time reducing the number of shared bedrooms. The home now caters for 44 residents, and specialises in caring for older people with dementia. The Lodge DS0000024437.V317341.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an Unannounced Inspection of The Lodge, a 44 bedded residential home for people over the age of 65 who have a diagnosis of dementia. The home is owned and administered by Gemini Care Limited and is situated in the village of Copdock which lies on the outskirts of the town of Ipswich. The inspection was carried out on 01 November 2006 over a period of 8 hours and 10 minutes. The key inspection focused on the care standards relating to care homes for older people. The report has been written using accumulated evidence gathered prior to and during the inspection. In advance of the inspection, the home was provided with service users and relative comment cards for distribution. At the time of writing twelve comment cards were returned to the Commission by relatives/visitors to the home. Comments contained in the feedback cards have been included within this report. The National Minimum Standards and Care Homes Regulations 2001 are referred to throughout this report and any non compliance identified. All key standards were assessed as part of this inspection. The Registered Manager was present throughout the inspection and the inspector had the opportunity to talk to staff, residents and relatives. What the service does well: The home provides a very homely and relaxed environment for service users who have complex and long term care needs. Accommodation provided is of a good standard and within the past eighteen months has been improved even further by the provision of two new wings which offer nineteen single rooms, all with ensuite accommodation. In addition to providing care to residents comments, made in comment cards and at the time of the inspection, indicated that family members appreciated the support offered to them by the staff and management of the home. The home should be commended on the level of meaningful activity offered to residents which is tailored to meet their needs and abilities. The Lodge DS0000024437.V317341.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. The Lodge DS0000024437.V317341.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 The Lodge DS0000024437.V317341.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): 1, 2, 3, 4 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users can expect to receive sufficient information on which to base a decision about whether they wish to live at the home. Residents living at the home can expect to be issued with a contract and a terms and conditions document. Residents could not necessarily expect in all cases to receive an individual assessment before moving into the home and therefore be assured that their needs could be met. EVIDENCE: The home has a Statement of Purpose and Service User Guide as required by Regulation 4 and 5 of the Care Homes Regulations 2001. A copy of this combined document has been submitted to the Commission for Social care Inspection. On the day of the inspection the Manager was unable to provide a copy of this document due to computer problems. However, the Manager The Lodge DS0000024437.V317341.R01.S.doc Version 5.2 Page 9 stated that when a prospective resident is allocated a place at the home, they are provided with a fact sheet about life at the home. The local authority has a block contract with the home for 27 beds. For the purposes of the inspection, the Inspector examined admission information on four service users selected for the purposes of care tracking. Two of the four residents had been placed on a private basis and both had been issued with a placement contract. The two other service users placed via the local authority were waiting to be issued with a contract via the placing authority. The placement contract issued by the home also includes details of the terms and conditions. It was noted that residents placed via the local authority did not receive a placement contract via the home although details regarding terms and conditions are contained within the Service User Guide. The Inspector examined the pre-admission information for the four service users selected for the purposes of care tracking. In the case of the two residents placed on a private basis, the home had carried out a pre-admission needs assessment although the information gained was limited. It was also noted that despite the home being registered to accommodate service users with a diagnosis of dementia, no evidence had been gained to confirm that either resident had a formal diagnosis. In the case of one of the service users placed via the local authority, a detailed community care assessment had been carried out and a copy provided to the home for consideration. The other resident placed by the local authority was done so as an emergency. Whilst some admission information had been provided in the form of a discharge letter from the hospital, no pre-admission assessment had been received from the placing authority or carried out by the home. The home was able to evidence that they do not provide an intermediate care service. The Lodge DS0000024437.V317341.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident living at the home can expect to be provided with an individual care plan which sets out how their assessed needs will be met. Residents can also expect that their physical and mental health care needs will be met. Whilst systems used for the administration of resident medication were appropriate, they did not necessarily offer total security. In general residents rights to privacy and dignity were upheld, although one shortfall was highlighted. EVIDENCE: As part of the inspection process, the Inspector examined the individual care plans for the four service users selected for the purposes of care tracking. In each case an individual care plan had been produced which provided staff with clear guidelines on the assessed needs of individuals and the levels of intervention required to ensure that these needs were met. All four care plans included an individual risk assessment and moving and handling assessment The Lodge DS0000024437.V317341.R01.S.doc Version 5.2 Page 11 The home was able to evidence that care plans were regularly reviewed and amended when individual needs or levels of dependency changed. Ten of the twelve comment cards returned by relatives/visitors reported satisfaction with the overall standard of care provided by the home. Two respondents however, indicated that improvements could be made in the quality of personal care provided to their respective family members. Care plans seen, evidenced that residents were supported and enabled to access community health resources and services such as GP surgeries, district nursing services, opticians and chiropody. All visits to service users by health and community services are recorded on a multi-disciplinary care planning sheet. Clinical guidance and support is derived from the Psychiatry of Old Age medical NHS team. A visitor to the home commented on how well their bedridden relative was looked after and how supportive the staff had been to them. The resident had been provided with a pressure-relieving mattress and documentation evidenced that they were being turned regularly and offered regular fluids. Another visitor assisting their family member to eat their meal commented that the care provided was first class and that the health of their family member had improved since coming to live at the home. During the inspection, the Inspector examined the systems and procedures used for the safe storage and administration of resident medication. The allocated staff member responsible for the administration of medication was observed carrying out the mid-day medication round. Medication was administered from a fit-for-purpose trolley, which was sited in the hallway. Resident medication was administered individually to each resident and the Medication Administration records signed. It was noted that when medication was administered to individual residents seated in the dining room, the trolley was closed but left unlocked in the hallway. This constituted a health and safety risk. Refused or spoiled medication was recorded on the Medication Administration Record and returned to the pharmacy on a monthly basis. The staff member administering medication had a good knowledge of how well and in what form individual residents accepted their prescribed drugs. The staff member advised that they had completed medication training some three years ago and would now benefit from refresher course. The Manager of the home was able to evidence that work packs for medication training had been purchased in order that refresher training could be carried out. Systems used for the storage of Controlled Drugs was examined and found to be secure and appropriate and accurate records of administration were maintained. Evidence was available to confirm that a weekly audit of resident medication and associated administration records was carried out. Observations throughout the inspection indicated that residents were treated with respect and their dignity maintained. Staff were observed to knock on bedroom doors before entering. All bedroom doors were fitted with privacy locks. All rooms, bar two, are offered for single occupancy and all nineteen The Lodge DS0000024437.V317341.R01.S.doc Version 5.2 Page 12 bedrooms sited in the new extension have ensuite facilities, thus offering maximum privacy. During the environmental tour of the premises it was noted that one of the shared rooms (Room 8) had not been provided with a privacy screen. The Lodge DS0000024437.V317341.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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents living at the home can be assured that they will be offered a range of meaningful activities which are appropriate to their needs and abilities. Residents can also expect that they will be supported to access community facilities and resources. Meal provision is of a good standard, although residents could not expect to be provided with a choice at each meal, or to be supported to make choices around this part of service provision. EVIDENCE: During the inspection, the home was able to evidence that it places a high importance on the provision of meaningful activities for residents. The manager reported that on his arrival at the home, some four years ago, very little activity was provided for residents. A summer fete was then held, attended by a local radio station, which raised £1500 and enabled a residents amenities fund to be opened. Since that time, functions held at the home have included summer fetes and an open-day when the new extension was The Lodge DS0000024437.V317341.R01.S.doc Version 5.2 Page 14 commissioned. Entertainers visit the home, including Ipswich Stagecoach and the professional singer Daniel O’Donnell whenever he is in Ipswich. A Senior Carer has the main responsibility for the provision of activity and produces a monthly activities plan which was seen at the time of the inspection. The plan for October 2006 showed that residents had been provided with a variety of activities including musical entertainment, craft sessions , flower arranging and floor games. The Senior Carer has completed a “reminiscence therapy” course via the North Anglian Open College Network. Recent reminiscence sessions with residents have included “How to make a Christmas Cake”. The home keeps a photographic portfolio of all its events, usually subtitled with amusing captions! One comment card returned to the Commission reported that “residents are always encouraged to take part in various games and activities that are played most afternoons”. The home has good links within the local community and part of the activities programme included entertainment provided by the local primary school. A three monthly newsletter is produced and distributed to over 70 contacts. A comment card returned to the Commission by a relative/visitor reported that whatever time the respondent visited the home they were never made to feel as if they were in the way. All respondents indicated that they were made very welcome by staff when visiting the home. The home was able to evidence that residents are provided with a planned menu of meals. Since the previous inspection a supper cook has been introduced to the home in order that care staff are no longer required to be involved in the preparation of the evening meal. Whilst the standard of meals provided was good, no choice was available for the mid day meal. In order to support residents in selecting a meal option, the Inspector suggested that the service may like to explore the use of digital photographs of plated meals. In general resident care plans reflected that service users are supported to make choices in other areas of their everyday life. The Lodge DS0000024437.V317341.R01.S.doc Version 5.2 Page 15 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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their families are provided with sufficient information to enable them to make a complaint about the service or to raise any concerns they may have. Policies and procedures adopted by the home seek to protect residents from any form of abuse. EVIDENCE: The home has a complaints procedure which is included as part of the Service User Guide and is also sent out to service users along with the placement contract. A copy of the complaints procedure is also displayed within the home and therefore accessible to all visitors to the building. The home maintains a record of complaints received and an audit trail of complaints investigations is available. Eight of the twelve comment cards returned by friends/relatives indicated that the majority of respondents were aware of the home’s complaints procedure, although the remaining four reported that they were not aware of this procedure. The home was able to evidence that it had a copy of the Local Authority Protection of Vulnerable Adults procedure and staff are required to sign to confirm that they have read it. Training on the recognition and reporting of The Lodge DS0000024437.V317341.R01.S.doc Version 5.2 Page 16 suspected abuse is derived either via NVQ Level 2 training or through the home’s own internal training programme. In September of this year a complaint was received by the Commission and referred to the provider for investigation. This complaint was appropriately investigated and changes have been made in relation to the involvement of care staff in meal preparation. The Lodge DS0000024437.V317341.R01.S.doc Version 5.2 Page 17 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents living at the home can expect to be provided with accommodation, both private and communal, which is comfortable, homely, well maintained and appropriate to their needs and abilities. Residents can also expect to live in an environment which is clean and hygienic, although facilities in relation to safeguarding against infection could be improved. EVIDENCE: The home provides accommodation for up to 44 older people who have a diagnosis of dementia. The home stands in extensive grounds and accommodation is sited on two floors both of which are accessible via a passenger lift. Two new wings were commissioned in December 2005 and provided an additional 19 bedrooms all for single occupancy and with ensuite facilities. The home has reduced the number of shared rooms on offer, The Lodge DS0000024437.V317341.R01.S.doc Version 5.2 Page 18 although two still remain, enabling residents to share accommodation should they wish to do so. Additional accommodation is available in the Coach House which is detached from the main building and is suitable for residents who are perhaps less dependant. A range of communal accommodation is available, including a large lounge and another smaller lounge for residents with higher dependency levels. The nineteen bedrooms provided within the new extension are spacious, furnished to a good standard with low level windows (fitted with restrictors) and under floor heating. Bedrooms within the older part of the building are also comfortably furnished and maintained to a good standard of decorative order and repair. It was noted that some bedrooms in the older part of the home were provided with vinyl flooring rather than carpet. There was no evidence to suggest that alternative flooring, such as carpet had been considered for these particular rooms. The Commission would always advocate the use of carpeting in bedrooms, as it is more comfortable for the resident, warmer and more homely. It was apparent that residents and their families had been encouraged to make their bedrooms as homely as possible with the addition of personal belongings, ornaments, plants and photographs. In addition to ensuite accommodation provided, the home has a sufficient number of communal bathrooms, with assisted baths and showers. Aids and adaptations were fitted around the home to aid mobility and handrails were provided in corridor areas. At the time of the inspection corridor areas were benefiting from redecoration. One comment card received by the Commission reported that since January a lot of work has been done regarding decorating and the planting of the garden. The laundry facility is sited in an outside building and has been equipped with a sluice cycle washing machine and tumble drier. Whilst the home had a procedure on the handling of soiled linen, the laundry room had not been provided with a hand-washing sink. Additionally whilst there are a number of residents who use a commode during the night, at the time of the inspection, no procedure was available in relation to the emptying, cleaning and storage of commode pots. The home does have a sluicing facility. The home has a large kitchen to the rear of the building. The Inspector was advised by the manager that there are plans to refurbish the kitchen and it was noted that it would benefit from redecoration. A kitchen cleaning rota was maintained which identified weekly and daily cleaning tasks. Whilst there were two fridges sited in the kitchen, these were running at 14c and therefore constituted a health and safety risk. It was confirmed by the Manager that replacement fridges had been ordered and delivery was imminent. All areas of the home were maintained to a satisfactory standard of hygiene and cleanliness. No unpleasant odours were detected in any area of the The Lodge DS0000024437.V317341.R01.S.doc Version 5.2 Page 19 building and the home should be commended on maintaining this standard taking into consideration the high needs of the majority of residents. The Lodge DS0000024437.V317341.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 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents living at the home can expect to be supported and cared for by a level of staffing which is appropriate to meet their special and complex needs. Residents can also expect to be supported and cared for by staff who have attained certain competency levels. Procedures currently employed in relation to the recruitment of staff did not necessarily ensure complete protection. EVIDENCE: On the day of the inspection residents were being supported and cared for by six members of care staff. The home ensures that a minimum of one senior staff member is in attendance on each shift. This level of staffing continues until 9pm in the evening when four staff members providing “waking” night care. In addition to care staff, three domestic staff are on duty to ensure that the environment is maintained to a good standard of cleanliness. The home also employs kitchen staff who are responsible for the provision of resident meals. A comment card returned to the Commission by a relative reported that the care of their family member at the home is excellent. They went on to comment that the relationship between their family member and the staff at The Lodge DS0000024437.V317341.R01.S.doc Version 5.2 Page 21 the home is also excellent and that they treat the resident concerned with great kindness and affection. The family member of one resident spoken to at the time of the inspection reported that they very much appreciated the support given to them by staff members. The Inspector observed that a good rapport existed between staff members and residents. Eleven of the twelve comment cards returned to the Commission indicated that there were a sufficient number of staff on duty to meet the needs of residents. The home was able to evidence that nine of the 23 care staff employed have achieved an NVQ qualification in either Level 2 or Level 3 in Care. An additional four care staff were currently undertaking an NVQ Level 2 in Care. The Inspector examined the recruitment files of two care staff employed since the previous inspection. Both staff members were overseas workers and although the home was able to evidence that they had both been subject to police checks in their native country, both had commenced duties at the home prior to a satisfactory POVA check and/or enhanced disclosure had been secured. Both staff members had been employed through an agency and therefore had not completed the home’s employment application form, although in each case had provided a comprehensive CV. Although satisfactory written references had been secured in the country of origin, in the case of one of the staff members selected for the purposes of tracking, only one written reference had been secured in relation to their employment by the agency the second was a general reference which had not been directed to any particular employment. The Inspector examined the training undertaken by the two selected staff members. In the case of one of the staff, the service was able to evidence that since coming to work at the home, they had undertaken a TOPPS Induction training programme which had included areas of mandatory training, such as moving and handling, food hygiene and health and safety. The staff member had also undertaken training in First Aid. The second member of care staff had been employed at the home since June of this year but since employment had been providing cover at another home owned by Gemini Care Ltd. At the time of the inspection, the home was unable to evidence that this person had been provided with a structured Induction training package or areas of mandatory training as the training records for this person were held at the service at which they were currently working. As the home provides care for older people with a diagnosis of dementia, all care staff are provided with annual training on this subject via the Alzheimer’s Disease Society. The Lodge DS0000024437.V317341.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, 36, 37 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst outcomes for service users are generally very positive, the best interests of residents were not completely safeguarded by the home’s recruitment procedures. In general the home provides a safe environment for service users. EVIDENCE: The Manager of the home, who has been in post for some four years, is registered with the Commission and had completed the Registered Managers Award in March 2005. The registered owner of the home maintains a presence there two or three times a week. Evidence was available to confirm that the owner is in the process of setting up a quality assurance system which includes The Lodge DS0000024437.V317341.R01.S.doc Version 5.2 Page 23 the recent distribution of service user and relative questionnaires. At the time of the inspection, some of the questionnaires had been returned and contained very positive comments in relation to the quality of the service provided. Whilst the home was able to evidence that staff supervision was carried out in the form of work monitoring and observations, the provision of formal one to one supervision was found to be weak. The home needs to be able to evidence that all staff are provided with an individual, formal and structured, supervision session at the recommended frequency of six times a year. The Manager advised the Inspector that the service does not have any involvement in the administration of resident finances. As service users have a diagnosis of dementia in most cases finances are administered by a family member, financial advocate or the placing authority. It was noted at the beginning of the inspection that the service did not maintain a record of all visitors to the home as required by regulation. The home was able to evidence that a detailed account of all accidents occurring in the home was maintained. Electrical and gas Safety certificates were both available for inspection. Fire records, which were examined as part of the inspection process, evidenced that fire alarm systems were generally tested on a weekly basis, although there was a gap of two weeks immediately prior to the inspection. Whilst the home was able to evidence that tests were carried out on secondary emergency lighting, records showed that this was only done on an annual basis, instead of a monthly basis as recommended by the Suffolk Fire and Rescue Service. The Lodge DS0000024437.V317341.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 2 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 3 3 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x N/A 2 2 2 The Lodge DS0000024437.V317341.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES 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 OP3 Regulation 14(1) Requirement The Registered Persons must ensure that no prospective service user is admitted to the home, as an emergency admission, without a needs led assessment being carried out and a copy of this assessment being provided to the home for consideration. The Registered Persons must ensure that when unattended the medication trolley is kept locked. The Registered Persons must ensure that all shared rooms are equipped with a privacy screen. The Registered Persons must ensure that a designated handwashing sink is provided in the laundry room. The Registered Persons must ensure that the home has a written procedure on the emptying, cleansing and storage of commode pots. The Registered Persons must ensure that all staff employed in the home must be in receipt of a satisfactory POVA first check DS0000024437.V317341.R01.S.doc Timescale for action 01/11/06 2 OP9 13(2) 01/11/06 3 4 OP10 12(4)(a) 13(3) 15/12/06 02/01/07 OP26 5 OP26 13(3) 08/12/07 6 OP29 19 01/11/06 The Lodge Version 5.2 Page 26 before they commence duties. This is a repeat requirement from the previous inspection dated 16/02/06 7 OP36 18(2) The Registered Persons must ensure that all staff receive structured and formal one to one supervision. Sch.4.17 The Registered Persons must ensure that a record of all visitors to the home is maintained. 13(3)&(4) The Registered Persons must ensure that refrigerators used for the storage of foodstuffs are maintained at a temperature of 4c - 8c. 23(4)(c)(v The Registered Persons must ensure that fire alarms within the home are tested At a frequency as stated in the home’s fire procedure and fire risk assessment. 23(4)(c)(v The Registered Persons must ensure that secondary emergency lighting is tested on a monthly basis and a log of these tests is maintained. 02/01/07 8 OP37 01/11/06 9 OP38 15/12/06 10 OP38 01/11/06 11 OP38 01/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP4 OP15 OP15 Good Practice Recommendations The Responsible Persons should ensure that wherever possible a written confirmation of dementia is secured prior to any resident being admitted to the home. The Registered Persons should ensure that residents are provided with a choice of options at each meal. The Registered Persons should consider the use of DS0000024437.V317341.R01.S.doc Version 5.2 Page 27 The Lodge 4 OP29 photographs of plated meals to support residents with limited communication to make a choice in relation to meal options. The Responsible Persons should ensure that employment references obtained for any prospective member of staff are specifically directed tot eh home or agency from where the home secures staffing. The Lodge DS0000024437.V317341.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 The Lodge DS0000024437.V317341.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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