Inspection on 18/10/07 for The Lodge

This inspection was carried out on 18th October 2007.

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

The inspector 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 09/10/08

The Lodge 08/05/07

The Lodge 12/07/06

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE The Lodge 29 Bargate Grimsby North East Lincs. DN34 4SN Lead Inspector Theresa Bryson Key Unannounced Inspection 18th October 2007 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 DS0000067509.V353278.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 DS0000067509.V353278.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Lodge Address 29 Bargate Grimsby North East Lincs. DN34 4SN 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) 01472 357774 nicolamcdonagh@bluecroftestates.co.uk Ramesh Dalton Murugupillai Rabindranath Rommel Selliah Position Vacant Care Home 29 Category(ies) of Dementia - over 65 years of age (29), Old age, registration, with number not falling within any other category (29) of places The Lodge DS0000067509.V353278.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th May 2007 Brief Description of the Service: The Lodge is a 29-bedded care home set near the centre of the town of Grimsby. The building is Victorian in style and retains many of its original features, but has a modern extension and large gardens. The home is equipped to provide care for those with dementia and problems of old age. It will also take up to 4-day care places. The home has a variety of sitting rooms and a dining area. The residents, who are able, can wander freely in the home as there is a digital locking system, for which the code is available, to ensure those less able do not leave the building unescorted, due to the very busy main road, through to Grimsby town centre. The home has bathroom and toilets on all floors and also a shower. The first floor is reached via a chair lift. The current scale of charges is £367 per week. Additional charges include hairdressing and chiropody. A statement of purpose and services users guide is available on request to ensure prospective service users are aware of the services the home can provide. Copies of the last inspection reports can be obtained from the manager on request and is available at all times in the main office. The Lodge DS0000067509.V353278.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit for this inspection took place over one and half days in September and October 2007. The half-day consisted of a short observational inspection where 5 people living in the home were observed over a 2-hour period and the second day was a full site visit day finding evidence to support a number of key standards. 8 staff were spoken to, 2 relatives and a number of records and documents seen during the site visits. Survey forms were also retuned from 6 relatives and 3 members of the local Social Services team were spoken to by telephone and at meetings. Prior to the visit days the inspector looked at what had happened in the home since the last inspection including a Local Authority Safe Guarding Adults Investigation. The home sent in their AQAA documentation and supporting evidence prior to the visits. The Acting manager and deputy manager were present through out the whole site visit days and one of the Owners joined the inspection on the last day. What the service does well: What has improved since the last inspection? Since the last inspection every body at the home have worked hard to do what was asked of them to make the home better. They have cooperated well with CSCI and other agencies and been very open and honest about how they see the running of the home and have seen lots of things improve. They should be The Lodge DS0000067509.V353278.R01.S.doc Version 5.2 Page 6 commended for their hard work and appear to have supported each other through this difficult process. The Statement of Purpose and Service Users Guide has now been reviewed and reflects the services the home can provide, to ensure people can make informed decisions about whether the home is right for them. This is now offered in a number of formats including large print, other languages and audiocassette. Contracts and terms of conditions about staying in the home are also now in place and signed to show that people living there are aware of what the fees cover and any other details appertaining to living in the home. More accurate records are now kept on each person to show that their current needs are being met and each need has been regularly evaluated and the care planned for that person. All people living in the home have recently been reassessed and the people themselves or their advocates have been consulted if necessary. Where a need has arisen the advice of other health care professionals or other agencies has been sought and this has been well documented. There was written evidence to support these are being monitored by a senior member of the management team to ensure the records are accurate and reflect the actual delivery of care to each person. This ensure that all parties are happy with the care being given and can have input into the planning of that care. The way of Controlled Drug medication is managed has improved and much clearer records are now being kept. The home has checked these drugs and all records are now accurate. This ensures people are free from harm of incorrect medication being given. The complaints policy and safe guarding adults policy has now been reviewed and clearer records kept of any concerns raised by individuals the investigation process and outcomes. This will ensure a good audit trail is in place and people can have feed back on any concerns raised and if not happy will know the further processes to follow. The home has been very cooperative with the CSCI, health and safety officer and fire officer to ensure the environment is properly maintained and safe to live in. there are now no outstanding issues regarding health and safety in the kitchen area and all radiators have been covered to ensure they are safe to use. The Owners have sent revised maintenance and renewal plans to CSCI and items covered have been checked and as per the plan been completed in the home. This has included a large amount of redecoration and refurbishment to better suit the needs of the people living there and ensures the home is safe. The Lodge DS0000067509.V353278.R01.S.doc Version 5.2 Page 7 The fire risk assessment has also bee reviewed and the home liaised with the local fire officer to ensure compliance regarding fire safety for all people entering the home. The staffing levels in the home and how work is allocated has been revised and this has ensured a reduction in falls in the home and relatives stating they feel there are more staff on duty and the care is being delivered to each individual to meet their needs. All staff files have been audited to ensure that every one is safe to work with the people living in the home. Their training needs have been reassessed and any gaps in knowledge base been planned into future training sessions. A number of topics have been covered in training including dementia, challenging behaviour and health and safety. This has included the Acting Manager. Supervision of staff has also taken place in both discussion time and observational supervision to ensure they are doing the job set before them and can delivery good and accurate care to each person. This has included all other departments as well as care staff as the home feels every one is part of the team to ensure people’s needs are being met. The home now has a revised policy and procudre manual, which is used by staff to ensure they are delivering the correct care and ensuring people are free from harm. Staff compliance with the manual is checked at supervision, through surveys sent out and by regular visits, meetings and discussions with the Owners and management team. The Owners now ensure that CSCI are aware of their visits by having open for inspection site visit forms to ensure they keep abreast of all aspects of the running of the home and that people using their services are having their needs met. What they could do better: There was still insufficient evidence to support that a wide range of social activities or contact with the local community are available in the home to meet the diverse needs of people living there. Failure to provide them could result in people being unhappy and not having their expectations met. The quality assurance system has improved since the last inspection, but there was insuffiecnt evidence to show a full range of topics covered or to show that the initial survey forms will be maintained. Failure to do so could result in peoples needs not being met and concerns from other agencies not being addressed. The Lodge DS0000067509.V353278.R01.S.doc Version 5.2 Page 8 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 DS0000067509.V353278.R01.S.doc Version 5.2 Page 9 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 DS0000067509.V353278.R01.S.doc Version 5.2 Page 10 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): Quality in this outcome area is good. People who use this service experience good quality outcomes in this area. Information is available; in a number of formats to ensure prospective service users can make informed decisions about the suitability of the home for them prior to admission. EVIDENCE: During the course of the visit Standards 1,2,3 and 6 were checked. Since the last inspection the management team at the home have revised the Statement of Purpose and Service users Guide documentation to ensure they both now reflect the services on offer, and prospective service users can make informed choice about the home. The Lodge DS0000067509.V353278.R01.S.doc Version 5.2 Page 11 Two formats were seen a normal and large print version and the manager also stated these can be offered in different languages and the audiocassette version was being prepared. At the time of the site visit the home was providing care for people funded by the Local Authority and privately paying people – who all had permanent residence. 1 person funded by the Local Authority on respite admission and 1 on day care admission. A number of contracts were seen of the Local Authority funded people and privately paying ones- each one had relevant dates, fees, terms and conditions and had been signed. 6 care plans were tracked in depth, but there had been no new admissions since the last inspection, due to the blocking of admissions by the Local Authority. Previous documentation was seen showing that an holistic tool is in use to assess each person prior to admission, which is under taken by the manager or deputy manager. This helps the staff prepare for an admission and ensures the home it can meet a person’s needs and that person feels the home can deliver the required care needed. The home does not provide intermediate care and therefore Standard 6 is not applicable. The Lodge DS0000067509.V353278.R01.S.doc Version 5.2 Page 12 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): Quality in this outcome area is good. People who use this service experience good quality outcomes in this area. Service users health and personal care needs are managed well and systems are in place to ensure any changes in need are responded to. EVIDENCE: During the course of the visit Standards 7,8,9 and 10 were checked. The management team and staff at the home had put in a lot of work since the last inspection, in updating all the care plans and ensuring staff are aware of the importance of accurate recording and communicating with people living in the home and relatives. There had been a number of outstanding requirements from the last inspection, all of which had been fulfilled. 11 survey forms were sent out by CSCI and 6 returned and 3 relatives spoken to by telephone. 3 surveys were sent to GP surgeries but none returned. 2 The Lodge DS0000067509.V353278.R01.S.doc Version 5.2 Page 13 relatives were spoken to on the day of the site visit, in the home. We also spoke to 3 members of the local Social Services team who stated the home was giving them adequate cooperation, especially when reviews had recently taken place for all people living in the home, funded by the Local Authority. All those surveyed made very positive comments about the staff and stated they felt communication was better and felt included in the care planning process. 6 care plans were tracked in depth. The documentation had been reviewed by the management team and slight changes had been made to ensure staff could accurately record the care delivered to each person. The records were much clearer to follow and there was good follow through when people had been seen by health care professionals and others. The daily report sheets kept on each person were now more detailed and we could follow the patterns of a person’s life and what events had taken place. There was documented evidence to show that not only the local Social Services teams had been involved in recent reviews but also families and friends of each person, as appropriate. The managers’ audits on care plans were also seen and detailed where evidence was not well supported and the process that then took place to ensure accurate records were being kept. The staff at the home had also been more diligent in sending to CSCI any untoward incident forms concerning events taking place in the home. When required these were also accompanied by relevant documentation from a person’s care plan for example accident report sheets. This has ensured that each person’s needs are now monitored more closely and staff are aware how to report changes and refer to other professionals relevant to a need. There were examples seen of referrals to the falls coordinator and community psychiatric nurses. Current needs appeared to be met and accurately recorded and audited. Prior to the site visit we had visited the home a couple of weeks beforehand and completed a short observational inspection. This entailed following the care of 5 individual people over a 2-hour period and noting any positive states of welling being and how they, staff, visitors and the environment were impinging on their well-being. Most people came out with very positive results concerning their well-being and appeared happy and contented. Some staff reactions and lack of understanding of peoples needs were fed back to the manager on the day and then on the site visit day documented evidence was seen on how the manager had addressed concerns with people living in the home and staff awareness and training issues. Visitors to the home made such comments to us as “staff really care about mum” and “it’s a good place for mum to be, the care is good”. The Lodge DS0000067509.V353278.R01.S.doc Version 5.2 Page 14 A referral had been made to the local Police concerning the documenting of Controlled Drug medication, after the last inspection. The home kept CSCI well informed of the progress and the conclusion was that there was no actual case to deal with by the Police, Safe Guarding Adults team or CSCI. Documented evidence was seen on this visit which showed adequate checking systems where in place to ensure people living in the home were receiving the medication prescribed to them and this was being administered using safe practises. Staff were able to describe the process of receiving, ordering and giving medication and appeared knowledgeable about the needs of individuals, when asked. The Lodge DS0000067509.V353278.R01.S.doc Version 5.2 Page 15 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): Quality in this outcome area is adequate. People who use this service experience adequate quality outcomes in this area. A more varied programme of activities needs to be in place to ensure the expectations of people living in the home can be met. A varied menu is prepared in a clean and safe environment. EVIDENCE: During the course of the visit Standards 12,13,14 and 15 were checked. Prior to the site visit, during the short observational inspection we observed that activities not appriate to a group of 5 were taking place. There had been little to no interaction between staff and people in the group and one person looked frightened by the activity of having a balloon thrown at them. A couple of people did enjoy a musical film and at times sang along to the vocals on the video, this how ever was interrupted by other activities in another room which were loud and intrusive to the group being observed. The Lodge DS0000067509.V353278.R01.S.doc Version 5.2 Page 16 The home has recruited an activities coordinator since the last inspection that works 15hours each week and has completed some training appropriate to their needs. The care plans tracked showed that each person had recently had a reassessment of their social needs and events were starting to be recorded. As this has only just commenced there was insufficient evidence to show a full range of events suitable to each persons needs and there was still limited links with the local community, but this was being worked upon, the manager and activities organiser stated to us. The management team needs to ensure that staff are being monitored and training given where necessary to ensure they understand the needs of this particular group of people. Work also needs to continue to develop community links and ensure each person’s expectations can be met to ensure they are content and happy in the home. There was better evidence to support that individual’s needs were being monitored in other aspects of the delivery of care. On a tour of the home rooms were seen where furniture had been moved to ensure a person was safe, pictures of family members were on display and colours in redecorated rooms planned to suit a person’s taste and gender. Relatives stated to us that “father is always wearing his own clothes” and “care is taken to ensure mother has her comfort soft toys around”. A brief tour of the kitchen took place as the local environmental health offer has been liaising with CSCI on visits to check compliance issues in the home generally and in the kitchen area. The day before the site visit the environmental health officer was contacted and there were no outstanding areas of concern in the kitchen area. The cycle of menus were seen and appeared varied and included fresh vegetables and fruit. The staff spoken to appeared to have a good knowledge base about individual’s needs and the diets being catered for by the kitchen. We were able to observe two meal times at the home on different visits recently. During the short observational inspection day kitchen staff particularly took care in telling people what each plate consisted of and other staff assisted people in a dignified way. On this site visit day the same applied, appropriate covering clothing was used for some people and different shaped cutlery for others. Staff spoke to each person calmly and were encouraging them to finish each meal, which helped them maintain a balanced diet. The kitchen area was clean and all safety checks were in place to ensure it was a safe environment to cook and work in. The Lodge DS0000067509.V353278.R01.S.doc Version 5.2 Page 17 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): Quality in this outcome area is good. People who use the service experience good quality outcomes in this area. Service users and their representatives know how to complain and were satisfied their discussions would be taken seriously. EVIDENCE: During the course of the visit Standards 16 and 18 were checked. The home is currently the subject of a safe guarding adults’ investigation led by the Local Authority Team. Since the last inspection an anonymous complaint was received directly to CSCI, which was discussed with the Acting Manager. Each point was raised and evidence shown to prove that any issue was either misleading or had been dealt with some time before the complaint had been received. Since the last inspection the complaints policy had been revised and a new complaints log commenced. A niggles book was in the main entrance notice board case and this showed 2 informal concerns had been raised since the last inspection. All evidence was seen and the records showed all parties were satisfied with the outcomes. No formal complaints had been made directly to the home. The Lodge DS0000067509.V353278.R01.S.doc Version 5.2 Page 18 Relatives spoken to stated they had every confidence in the new Acting manger to deal with any concerns and felt staff had become better in communicating details to them about their loved ones. The updated policy for safe guarding adults was also seen as well as the health and safety policy and staff are starting to sign to say they have seen revised policies and the newly laid out policy and procedure manual. A training audit had also been completed since the last inspection and this showed which staff required update training in safe guarding adults. Evidence was seen in letter format of the staff enrolled on a course later in October 2007. This will ensure that people wishing to raise a concern have the necessary information to enable them to do so and that a policy is in place to ensure each concern is dealt with promptly. The updated training matrix format will ensure that the management team are aware where staff need up date training and ensure people living in the home are looked after by adequately trained staff who can protect them from harm. The Lodge DS0000067509.V353278.R01.S.doc Version 5.2 Page 19 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. People who use this service experience good quality outcomes in this area. People live in a safe and secure environment suited to their needs. EVIDENCE: During the course of the visit Standards 19 and 26 were checked. The local health and safety officer and fire officer have recently been assisting the home to ensure that people living there and staff working in the home and visitors are safe, when entering the environment. The health and safety officer still has one issue outstanding, but is keeping the CSCI informed about visits. The home has completed a lot of refurbishment work since the last inspection and has kept the CSCI informed with updated action plans and a new The Lodge DS0000067509.V353278.R01.S.doc Version 5.2 Page 20 maintenance plan, which shows areas covered and completed and those still outstanding. During the course of the site visit we toured the building alone and also with the Acting Manager and one of the owners. All toilets, bathrooms and communal areas were seen as well as a selection of individual rooms. Some redecorating had taken place and each individual person has their name on the door, when agreed with themselves or their advocates. Each bathroom and toilet door is now painted red for ease of identification by people living in the home and all lounge areas and the dining room and corridors had been painted. This has given the home a more light and airy look and the subtle hues make for a calming environment in which to live. Evidence was seen that the corridor carpets were to be replaced the following week. The home management team has been liaising with the local fire brigade and health and safety officer to ensure all radiators in all areas of the home are now safe and people are safe to be near them. All this large piece of work was completed on this site visit and all covers had been painted to blend in with the current redecoration scheme. This will ensure every one is safe if they should lean against them. The staff need to be commended for their hard work in this area of managing the home and how they have liaised with outside agencies, people living in the home, relatives and health professionals to ensure the home has been adapted to suit the needs of each individual and it is a safe, secure and a calming place in which to live and work. Some concerns had been raised with us about the laundry provision by relatives, who felt it was not perfect and some mistakes had been made regarding dirty clothing found in drawers sometimes, and some bed linen and personal clothing appearing un-ironed. We inspected the laundry area which was clean and tidy, but a very unwelcoming environment in which to work as it was dark and in an outside building. The area into the reception courtyard to the laundry could be breached from the outside and was a potential risk for intruders to be able to hide close to the home and make possible entry. Suggestions were made by the management team and owner as to how this could be made more secure and welcoming. Bed linen and personal clothing appeared ironed on the site visit day, but some towel supplies needed auditing as some in peoples room were in a poor state or repair. There were ample supplies of linen and towels. The Lodge DS0000067509.V353278.R01.S.doc Version 5.2 Page 21 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): Quality in this outcome area is good. People who use this service experience good quality outcomes in this area. Staff are adequately checked prior to employment and are safe to work with the people who live in the home and are then trained to do their jobs. EVIDENCE: During the course of the visit Standards 27,28,29 and 30 were checked. A great deal of work had been undertaken by the management team since the last inspection in ensuring that all staff had received adequate checks prior to commencing employment. The recruitment and personal file of the manager was checked and all security checks and references made by the Owners. Written evidence was also seen that all staff files had been audited to ensure previous checks and information was included on file. A selection of 6 were tracked in depth and found to have sufficient evidence on file to ensure they were safe to work with the people who live in the home. This included valid contracts, Criminal Records Bureau checks, application forms and medical questionnaires. Some new staff had been recruited and a new interview format was in place, which showed fairness in the questions asked and challenges made to application forms. Job descriptions were in place for each grade of staff and The Lodge DS0000067509.V353278.R01.S.doc Version 5.2 Page 22 signatures obtained when certain policies such as health and safety, uniform policy and training induction packages were handed to staff. This ensures that each person is safe to work with the people who live at the home and will be suitable to take on the role described to them. A training and skills audit had also been completed for all staff and documented evidence seen that this had taken place. The new format clearly identifies gaps in some staff training, but also courses already completed, some of which required up dates to be completed in for example basic food hygiene and safe guarding adults. Since the last inspection staff had attended a variety of mandatory training days such as manual handling and fire, but also some service specific ones such as dementia, challenging behaviour and nutrition. 46 of staff had already completed their NVQ to at least level 2 and some were enrolled on a current course. This will ensure that they are trained to do their jobs with the latest research based evidence to work with for the benefit of all people living in the home. The Local Authority had been liaising with the home and CSCI over the care of one individual and sufficient evidence was produced before the site visit, which was checked again at the site visit that sufficient staff were always on duty to meet that person’s needs. The Local Authority and family appeared satisfied that all needs were currently being met. The Acting Manager is now using the Residential Forum Matrix to ensure there are sufficient staff on duty to meet the needs of people living in the home at all times. Evidence was sent prior to the site visit and checked on the day. The home had 2 vacancies for care staff, which was being allocated to current staff, who appeared to be working better as a team. All other departments were working with a full staff complement and no problems were identified when speaking to staff, people living in the home, relatives and visitors. Some professionals interviewed stated they felt that basic skills were present with staff and relatives stated there always appeared to be enough on duty to met their loved ones needs. The Acting Manager stated that since the last inspection there had been a reduction in falls in the home and other incidents as the way staff are allocated to complete the work to met current needs of service users had changed. There was written evidence to support the different working ways seen, which staff also confirmed verbally and the reduction in falls were noted and seen in the accident audits produced for inspection. It is still vital that the Owners and management team appreciate that staffing levels must be maintained to meet the dependency levels of people living in the home to ensure they are free from harm and all their needs can be met. The Lodge DS0000067509.V353278.R01.S.doc Version 5.2 Page 23 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): Quality in this outcome area is adequate. People who use this service experience adequate outcomes in this area. Some systems are in place to ensure the home is run for the benefit of the people living there, but need to be expanded and show a continuing record of consultation with the people and other agencies. EVIDENCE: During the course of the visit Standards 31,33,35,36 and 38 were checked. Since the last inspection the Owners of the home supplied written evidence to CSCI to show that adequate safety checks had been made on the Acting Manager and their records of the interview process and references taken up to see whether that person was capable of running the home. These were satisfactory for CSCI purposes. The Lodge DS0000067509.V353278.R01.S.doc Version 5.2 Page 24 The Acting Manager offered a copy of the quality assurance report completed by the home team for 2007. This showed audits on surveys sent to relatives and others and included topics such as personal care, laundry, privacy and dignity and health. The home has also commenced monthly relatives meetings and the minutes of those and of 2 staff meetings were also seen. Relatives and staff spoken with stated they found the meetings useful and felt they could voice their opinions to the management team and any concerns and issues were addressed and feed back given, where required. This has started the quality assurance process well, but needs to be further expanded to show further interaction with outside agencies and visitors to the home and encompass the auditing of other aspects of running the home, such as the good accident statistics now kept by the Acting Manager. There was insufficient evidence at the time of this site visit to show that this was an on going process and will need expansion to show continued commitment to the process. Auditing of this nature will ensure that the management team are aware of the needs of the people living in the home, any concerns raised and also value comments by them, other agencies and staff, to ensure the home is run for the benefit of those people living there. We were assured at this visit by one of the Owners that there were no bad debtors to the home and no money is held for people’s personal living allowances. No concerns have been raised since the last inspection concerning the home’s financial viability. There was sufficient evidence in the home to show that since the last inspection the Acting manager has worked hard with the deputy to ensure that supervision records of staff are being kept up to date. A new format was seen to be in place, which looked at previous discussions, issues raised, training concerns or events planned or been to and hen action planning. Each one seen had been signed by the supervisor and staff member. Staff were able to quote to us their feelings on these sessions and generally felt they were a way forward to ensure they are kept up to date in their practises and can plan their training and career needs. Of the ones seen the records showed a good balance of discussion times and also observational supervision. The Acting Manager keeps a yearly planner for all staff to ensure no sessions are missed. This assures people living in the home that a senior staff member is monitoring the work of staff members and any issues can be monitored to ensure they are delivery good care to individuals. The file was also produced for inspection, which showed that the management team are keeping the necessary checks up to date to ensure the home is safe. All certificates were valid and the file also contained evidence of checks made The Lodge DS0000067509.V353278.R01.S.doc Version 5.2 Page 25 by the team such as health and safety checks, water temperature checks and fire checks. The fire risk assessment has been reviewed since the last inspection and passed by the local fire officer. Details of fire training were now also on record and evidence seen that more sessions are planned. Immediately after the last inspection the Owners were asked to send to CSCI copies of the site visitors they made to the home under Regulation 26 notices. This they did and have now been asked to stop as the evidence shows visits are made regularly. They still need to be open for inspection at any time and need to be kept in the home. This ensures they are aware of how the home is run and can liaise with all parties using the facilities. Relatives spoken with stated they had had one to one contact with the Owners and they were pleasant when in the home and attended events with their families. The policy and procedure manual has also been reviewed and there was documented evince to show which policies had needed to be revised. Staff were beginning to sign to say they have re-read these policies, which ensures they are keeping themselves aware of any new ways of working. The Lodge DS0000067509.V353278.R01.S.doc Version 5.2 Page 26 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 3 X X N/A 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 2 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 3 X 3 The Lodge DS0000067509.V353278.R01.S.doc Version 5.2 Page 27 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 OP12 Regulation 16.2.m Requirement Appropriate activities to suit the needs of service users must be provided. (Previous timescales of 14/08/06,31/12/06 and 30/04/07 and 30/06/07 not met). Appropriate links must be made with the local community to ensure service users expectations of being part of an integrated community are fulfilled. (Previous timescale of 30/07/07 not met). Facilities for laundering services should be kept in a good state of repair and be a safe place in which to work. There must be a quality assurance system using a verifiable tool in place to ensure all aspects of the home are monitored and the views of service users are taken into account when decisions are being made. (Previous time scale of 30/08/07 not met). DS0000067509.V353278.R01.S.doc Timescale for action 28/02/08 2. OP13 16.2.m. 28/02/08 3. OP26 23.2.o. 28/02/08 4. OP33 24.1.a, b. 28/02/08 The Lodge Version 5.2 Page 28 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 DS0000067509.V353278.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Hessle Area Office First Floor 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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. 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