Inspection on 12/09/06 for The Lodge

This inspection was carried out on 12th September 2006.

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

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

Other inspections for this house

The Lodge 09/11/07

The Lodge 21/12/05

The Lodge 26/04/05

The Lodge 02/11/04

The Lodge 20/04/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE The Lodge 8 Lower Road Bedhampton Havant Hampshire PO9 3LH Lead Inspector Tracey Box Unannounced Inspection 12th September 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Lodge DS0000011643.V310218.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 DS0000011643.V310218.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Lodge Address 8 Lower Road Bedhampton Havant Hampshire PO9 3LH 023 9245 2644 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) The Manor Trust (Bedhampton) Mrs Janette Waller Care Home 14 Category(ies) of Old age, not falling within any other category registration, with number (14) of places The Lodge DS0000011643.V310218.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th April 2005 Brief Description of the Service: The Lodge residential home is part of an integrated scheme run by a trust (Manor Trust) as a registered charity, in the area for the care and accommodation of older people. Accommodation is provided at other locations (The Manor House, The Elms and The Waterloo Room) for people who are more active and not in need of personal care (but who receive companionship and support). The Lodge came into being in 1981 to meet the needs of people who were becoming too frail to live independently at the Manor House/Elms. The home provides accommodation on the ground and first floors. Local amenities, bus and rail links are within easy reach. The home is surrounded by landscaped gardens and is situated in a quiet, scenic area. It has 14 single bedrooms (8 of which have en-suite facilities) and good communal areas. Twenty-four hour care is provided with 2 members of staff (awake) on duty at night. The Lodge DS0000011643.V310218.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The people living at The Lodge prefer to be referred to as residents, therefore the rest of this report will reflect this The opportunity was taken to look around the home, view records, procedures and talk with residents and staff. The inspector also had the opportunity to observe the interaction between residents and staff. Two residents were spoken with who stated that they were happy at the home. The staff on duty during this visit felt they were supported to do their job. Two relatives said they were very happy with the care and support their relative receives, they are made to feel welcome at the home. The manager confirmed the fees for the home range between £1510.00 £1650.00 per month. What the service does well: What has improved since the last inspection? What they could do better: The manager must ensure staff receive training in the administration of medication and food hygiene. Staff would benefit from receiving formal supervision from an appropriately trained member of staff. The Lodge DS0000011643.V310218.R01.S.doc Version 5.2 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Lodge DS0000011643.V310218.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 DS0000011643.V310218.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 & 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents receive information about the home that will enable them to make an informed choice. The home have a comprehensive pre admission assessment form which enables each resident to be fully assessed to ensure the service users needs can be fully met by the home. The home does not provide intermediate care. EVIDENCE: The manager has revised the home’s statement of purpose, which sets out the aims and objectives of the home and includes a service user’s guide providing basic information about the service to existing and prospective residents. One resident confirmed they had received a copy. The pre admission form has been greatly improved, the manager or the deputy complete these assessments, which they say are easy to follow and more comprehensive. The inspector looked at the most recent pre admission assessment records, which included a hospital and social workers assessment, The Lodge DS0000011643.V310218.R01.S.doc Version 5.2 Page 9 the manager visited the prospective resident to complete the home’s pre admission assessment, the resident’s family were involved providing information also. The pre admission assessment includes a moving and handling, clinical and functional assessments. The manager confirmed she is appropriately qualified to complete these assessments. The manager confirmed the home do not provide intermediate care. The Lodge DS0000011643.V310218.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans reflect the individual’s health, personal & social needs which ensure their personal needs are met. Residents are protected from the homes medication policies & procedures, however training needs to be arranged for staff who administer medication. Residents feel they are treated with dignity and respect & that they are given information to enable choice. EVIDENCE: Staff said the care plans provide them with the information they need to support the individual in their own home. One resident confirmed they are fully aware of, and are included in the reviewing of their care plans and risk assessments, however the inspector looked at three care plans and risk assessments and records showed that they had not been reviewed within the last three months, one night care plan had not been reviewed since February 2006. The manager confirmed she would ensure care plans and risk assessments are reviewed every three months, or sooner if individual’s needs change. The Lodge DS0000011643.V310218.R01.S.doc Version 5.2 Page 11 The inspector witnessed medication being administered in accordance with the homes policies and procedures by two members of staff, one of which was a senior. The recording procedures were found to be correct, and the staff said they receive regular monitoring by the manager, as well as training in administration of medication. However, certificates showed this training was completed over eighteen months ago, therefore the manager will arrange training for all staff to attend administration of medication training. Staff induction records showed that privacy and dignity and the provision of personal care are covered during the induction process, and the response from residents indicated that the carers treat them with dignity and respect and that they are trustworthy. One resident told the inspector that staff respected their choice and privacy at all times. The inspector witnessed staff talking to service users in a respectful manner. Staff said they are aware of the importance of dignity and respect, one staff said “ I treat people as I wish to be treated”. The manager confirmed that policies and procedures are reviewed and available for staff to access regarding residents health and personal care, and that residents access healthcare professionals when required. Records of doctor, chiropodist and physiotherapist visits were part of individual’s care plans. The Lodge DS0000011643.V310218.R01.S.doc Version 5.2 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): 12,13,14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents social, cultural and religious needs are met and they are able to participate in a programme of suitable activities, receive visitors as they wish and are offered a choice of nourishing well-presented meals served in a relaxed atmosphere. EVIDENCE: Residents spoken with said that they were able to exercise choice over their daily living activities and participate in a variety of things, which include quizzes, musical movement, card games, word searches, crosswords, walking around the grounds and various board games. The manager said she is qualified in therapeutic massage and aromatherapy massage, reflexology, manicure and pedicure treatments. The manager confirmed that policies and procedures are in place to ensure residents are supported to lead active lives as they prefer, care plans reflected this. The registered manager said that there were no residents from an ethnic minority at present but that if a resident had cultural or religious interests every effort would be made to accommodate them. The home has an open visiting policy. This was evidenced by records of visitors to the home and The Lodge DS0000011643.V310218.R01.S.doc Version 5.2 Page 13 confirmed by relatives and one relative, who confirmed they visit at different times of the day and are always welcomed. The inspectors observed residents eating lunch in the dining room, the atmosphere was relaxed, residents were offered choices of main meal and desserts. Cold drinks, tea and coffee with biscuits were available throughout the day and staff are able to access the kitchen at night to provide hot drinks and snacks for residents who wish them. The cook said that vegetables are grown in the garden and used in cooking as and when available. The fridge was well stocked with fresh produce, all foods were covered and dated. The Lodge DS0000011643.V310218.R01.S.doc Version 5.2 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints procedure, which residents feel able to use and an adult protection procedure to safeguard residents from abuse. EVIDENCE: Residents spoken with were aware of whom to complain to, should they have a need to, although at present they were happy with the care they receive. Records of complaints received were logged on an incident sheet, sufficient details showed timescales and outcomes, however the manager said she would log complaints received in a file specifically for complaints. One staff said ‘I am aware that reporting any concerns or complaints is important to improve things, I know that I should speak with the manager, or the owner if it is about the manager. I have received training in Adult Protection issues.’ The home have included the corporate Hampshire County Council and adult protection procedure, which includes a whistle blowing policy. The manager confirmed that policies and procedures are reviewed and available for staff to access regarding complaints and protection, and that staff receive training in Adult protection, training records were available to support this. The Lodge DS0000011643.V310218.R01.S.doc Version 5.2 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 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment provides residents with a warm and comfortable home. There is a good infection control procedure at the home to safeguard the welfare of residents. EVIDENCE: The home was warm and welcoming, all parts of the home seen ware well maintained and tastefully decorated. There was ample communal space, the home has two lounges and a dining room. Residents live in comfortable bedrooms. It was evident that residents are encouraged to bring in items of personal belongings. The Lodge DS0000011643.V310218.R01.S.doc Version 5.2 Page 16 One resident commented about the “lovely” garden and the views from their rooms and communal areas. Seating was available and the garden was accessible to residents. The home has an internal laundry that was well maintained. Infection control procedures were in place. Staff were observed to follow these guidance, equipment such as gloves and aprons were available. The inspector saw certificates showing staff had received infection control training. The Lodge DS0000011643.V310218.R01.S.doc Version 5.2 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): 27,28,29 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The majority of staff are appropriately trained, there is sufficient skill mix within the team and to meet the residents needs. The recruitment procedure for the home ensures the vulnerable people living in the home are protected. EVIDENCE: The home has sufficient staff numbers and skill mix to meet the residents needs. The home has a duty rota which reflects this. Staff confirmed there are enough staff on duty to meet individual’s and group needs. It was evident from practices and interactions observed that staff had developed good relationship between themselves and residents. Comment from residents included that staff were very kind and always helpful and that they were a “good team”. One resident praised the domestic staff for their hard work in keeping their bedrooms clean and tidy. The inspector examined copies of three staff recruitment records. These were all found to be in order. There was evidence that written references had been obtained, application forms had been completed and evidence of personal identification was available. Appropriate checks had been undertaken with the Criminal Records Bureau and the Protection of Vulnerable Adults register. New employment contacts had been supplied by the company to all staff. Staff confirmed they are working towards their induction and foundation standards in line with skills for care guidelines. The Lodge DS0000011643.V310218.R01.S.doc Version 5.2 Page 18 The manager explained at present the majority of its workforce either working towards, or have achieved National Vocational Qualification (NVQ) levels 2 and 3. The inspector sampled records of the fire drill log, which shows un announced fire drills occur regularly, all records of fire alarm and equipment were satisfactory. The manager explained staff have received adequate training, and three staff said they had received appropriate training to enable them to carry out their role correctly, certificates were available to show that staff have attended mandatory training in health & safety, moving & handling, first aid, fire safety and infection control. To ensure residents health and welfare, the manager must ensure staff receive training in the administration of medication. Evidence of the cook receiving recent food hygiene was not available, therefore the manager must arrange for all staff who deal with the preparation and cooking of foods to receive food hygiene training as a matter of urgency. The Lodge DS0000011643.V310218.R01.S.doc Version 5.2 Page 19 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): 31,33,35,36 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a home that is managed well and run with their best interests in mind. The home’s procedure for dealing with the majority of residents’ finances is good, however the procedure needs reviewing in order to safeguard residents interests. The procedures and practices for the health and safety of residents and staff are good EVIDENCE: The manager has been registered with the CSCI since January 2006 and is currently recruiting a deputy manager. The Lodge DS0000011643.V310218.R01.S.doc Version 5.2 Page 20 The home has an internal audit system in place that seeks the views of residents, relatives and other healthcare professionals on a regular basis. Records of feedback from residents seen demonstrate that there is a high degree of satisfaction regarding the care provided. Comments such as ‘Staff are very polite, always helpful and always listen to me’ were included in the feedback. Minor negative points identified by the manager in an action plan have been dealt with. The manager said she will be sending a satisfaction survey to relatives in the near future. The provider undertakes monthly reviews of the environment, residents and staff views are sought and reports of these are available to the Commission, either when an inspector visits or they would be sent to the Commission if requested. Six residents handle their own financial affairs, the home store their money and corresponding records safely. The inspector looked at these records and they were found to be correct records of the money held. The inspector looked at the homes policy regarding safeguarding residents finances, which stated no more than £50.00 is to be held in the home in respect of each resident, however one amount of money being held was £186.36. The manager said she would rectify this matter by speaking to the resident and their relatives. The manager confirmed residents can access their money during office hours, Monday to Friday, so forward planning is needed to ensure residents have enough money for the weekend. The manager said relatives send money to the resident as and when they need it, the home safeguard the money until it is needed. One resident said ‘if I need any money I get it, I sign to say how much I have received, and another member of staff confirms this amount.’ The staff confirmed they receive in formal time with the manager, and can discuss and issues or concerns at any time, however these discussions are not formalised, therefore the manager must ensure staff receive regular formal supervision by an appropriately trained person. Staff said they feel supported by the manager. The home has a policy, procedures and information on health and safety. A sample of policies and procedures was seen and it showed that these are reviewed regularly. All COSHH materials are maintained safely. There is an ongoing system in place that ensures that all appliances are serviced. The employer’s insurance liability certificate was displayed and current. The Lodge DS0000011643.V310218.R01.S.doc Version 5.2 Page 21 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 X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 3 The Lodge DS0000011643.V310218.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No . STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2. Standard OP30 OP30 Regulation 18 (1,a) 18 (1,a) Requirement The manager must ensure staff receive training in the administration of medication. The manager must ensure staff receive training in the administration of medication and food hygiene. The manager must ensure staff receive regular formal supervision by an appropriately trained person. Timescale for action 12/10/06 12/10/06 3. OP36 18 (2) 12/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Lodge DS0000011643.V310218.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 The Lodge DS0000011643.V310218.R01.S.doc Version 5.2 Page 24 - 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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