Inspection on 28/04/05 for The Lodge

This inspection was carried out on 28th April 2005.

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

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

Other inspections for this house

The Lodge 18/08/09

The Lodge 02/12/08

The Lodge 09/01/08

The Lodge 11/04/07

The Lodge 19/04/06

The Lodge 05/07/05

The Lodge 04/10/04

The Lodge 17/05/04

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

CARE HOMES FOR OLDER PEOPLE The Lodge Watton Road Ashill Thetford IP25 7AQ Lead Inspector Christopher Handley Unannounced 28 April 2005 9.30am The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Lodge I55 S27322 The Lodge V224063 280405 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Lodge Address Watton Road Ashill Thetford Norfolk IP25 7AQ 01760 440433 01760 440043 kaz1509@hotmail.com Mr Kenneth John Squire Mrs Irene Margaret Squire Mrs Karen Syer Care Home 20 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Category(ies) of Old Age (20) registration, with number of places The Lodge I55 S27322 The Lodge V224063 280405 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4 October 2004 Brief Description of the Service: The Lodge is a residential home registered for 20 elderly people. The home was originally a large detached family home, and it retains many of its original features. There is a large lawn at the front of the home which provides a good sitting out area for residents, with smaller gardens at the side and rear of the home.There is a car park at the front of the home. If nursing care is required it is provided by members of the District Nursing team. Any medical or specialist sevices are obtained via the GP service. The home is situated on the outskirts of the village of Ashill, on the Swaffham to Watton Road (B1077). The Lodge I55 S27322 The Lodge V224063 280405 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an un announced inspection and was carried out as part of the annual inspection programme. Documentation was inspected, and a tour of the home was undertaken. Six residents and four members of staff were interviewed. A total of 18 standards were inspected. The inspection was taken by Mrs K Syer, the Manager of the home. What the service does well: What has improved since the last inspection? The pre admission assessment is new, and has improved since the last inspection. The care planning has improved, it is more structured. The upstairs environment has improved since the last inspection. The Lodge I55 S27322 The Lodge V224063 280405 Stage 4.doc Version 1.30 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Lodge I55 S27322 The Lodge V224063 280405 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection The Lodge I55 S27322 The Lodge V224063 280405 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2,3,&5 All residents are provided with a detailed Terms and Conditions. Detailed pre-admission assessments are carried out on all prospective residents. Residents and their relatives are positively welcomed to visit the home prior to admission. EVIDENCE: All residents are provided with a detailed Terms and Conditions, a copy of which was seen. This document is an agreement between the residents and the home. It clearly sets out the service, which the residents will be provided with. A member of staff sits with the resident and goes through the documents to ensure that the resident/relative has a clear understanding of the contents of it. The residents retain a copy and a signed copy is kept in the office. The Lodge I55 S27322 The Lodge V224063 280405 Stage 4.doc Version 1.30 Page 9 Residents interviewed said that before they came to the home they were given information about the home. A detailed pre-admission assessment is undertaken by the Manager on all prospective residents to ensure that the home can meet that persons needs. A copy of this document was seen, it is new, detailed, and comprehensive. This assessment when completed provides the basis for a decision to be made as to whether the home can meet the individual’s needs. The assessment visits are carried out by arrangement, and identification is carried in order to protect the security of the prospective resident. Prospective residents and their relatives are positively welcome to the home in order that they get a detailed picture of their future home. During these visits they tour the home, speak to other residents and staff, and are provided with written information about the home, the Manager said. Some of the residents spoken to confirmed that they and their relatives had visited the home prior to admission. The Lodge I55 S27322 The Lodge V224063 280405 Stage 4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,&9. All residents have an individual care plan. The residents’ health care needs are assessed and met. Steps are being taken to make the storage of Controlled Drugs safer. EVIDENCE: All residents have an individual care plan, which have the essential elements of assessment, planning, implementation and review. The assessment includes the physical, mental and social needs of residents. They describe the care needs required and how these will be met. A detailed daily record is maintained. this provides a brief but succinct record of the day or night. A very detailed risk assessment is carried out and recorded. The Lodge I55 S27322 The Lodge V224063 280405 Stage 4.doc Version 1.30 Page 11 The care files are marked “Confidential Information” and are kept secure. Residents and relatives are involved in the reviews of care. The care plans improve year on year and this ensures that more effective care can be planned, implemented, and monitored with the residents being part of the care process. The health care needs of the residents are assessed, and their health care needs are then met in the home, by staff or visiting professionals, or in the local hospital or surgery. All residents have a GP. The home medicines are kept in a locked cupboard. Only staff that are trained administer medicines. Medicines are clearly recorded, and are regularly reviewed. The medicine cupboard was neat and tidy. There were no controlled drugs in the home on the day of the Inspection. In the last inspection a requirement was made that the home purchases a Controlled Drug Cupboard, this has been done and it is to be fixed in place in the very near future, as part of the upgrading of the medicine room. The home has a detailed and comprehensive procedure for the reception, storage, administration, and disposal of medicines, which was seen. The training and procedures of the home ensures the safety of residents in this matter. The Lodge I55 S27322 The Lodge V224063 280405 Stage 4.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 & 15 The home provides a good catering service. The residents like the activities provided. EVIDENCE: The routines of daily living in the home are set around the needs of the residents. There is a quiet relaxed pace to the day, which meets the needs of some residents, whilst others said that they like to be “ busy”. There is a range of activities provided, which residents said that they liked, including bingo and singing which seemed particularly to be enjoyed. Some residents prefer sitting quietly in their rooms, reading a book or newspaper It is the Manager’s intention to further improve the range of activities by undertaking training in this matter. There is a four-week menu, which was seen, it is nutritious, varied, and interesting. Special Diets are recorded. The residents spoke highly of the meals provided; “There’s always enough” and “They are very nice” were two of the comments made. The cook makes every attempt to meet even the smallest wishes of residents in regard to food, as she is aware that it plays an important part in their day. If needed the Manager would seek advice from the Dietician. The Lodge I55 S27322 The Lodge V224063 280405 Stage 4.doc Version 1.30 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 The home has an effective practice in regard to dealing with complaints. The complaints procedure is known to residents. Staff are aware of the home’s Adult Abuse Protection policy. EVIDENCE: The home’s complaints procedure was seen, it is posted up in the reception area of the home. It is in large print and is clearly set out. Both staff and residents spoken to were aware of how to make a complaint, and briefly described this, the main element of this being, that they would see the Manager. The Manager said it was the practice of the home to deal with any concerns very quickly, and by so doing allay any worries or concerns which residents may have. Since the last inspection the home has received a complaint, which is recorded, and CSCI were informed of this. The Manager investigated the matters concerned, which was that poor quality of care was being provided, and none of the elements were substantiated. The home has an Adult Abuse Protection procedure, which was seen. Staff were aware of this. When asked they knew what their role was and what they should do. It forms part of the induction of staff. To further enhance staff knowledge in this matter, the Manager is arranging a training session for staff. The Lodge I55 S27322 The Lodge V224063 280405 Stage 4.doc Version 1.30 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 & 24 The improvement work on the ground floor has not yet been completed. The improvement work on the first floor has been completed. Resident’s rooms have a comfortable and homely appearance. EVIDENCE: The home is suitably located and there are pleasant grounds at the front of the home, with lawns and flowerbeds. There are benches for residents to sit out The building complies with the requirements of the local Fire Service and Environmental Health Department. The Lodge I55 S27322 The Lodge V224063 280405 Stage 4.doc Version 1.30 Page 15 For some time now the home has been undergoing a major renovation programme, and work on the first floor has been completed. The work on the ground floor continues and some of this has been completed, door widening, and handrails have been put in place. There is still considerable work to be completed. Whilst this work is being undertaken, care is being taken to ensure the safety of residents. The Proprietor said it is anticipated that the work in the middle part of the corridor will be completed within the next two weeks. The home now has a written improvement plan which should ensure that maintenance work is kept up to date, and prevent major backlogs of work occurring. During the inspection ten rooms were seen. They were neat clean and tidy. They had a variety of ornaments, pictures and personal items. It was obvious that the residents had personalised them to their own choice. The state of decoration is good, as is the condition of the furniture. The residents said that they thought that their rooms were very nice, they were “Comfortable and warm” “ Its my part of the world where I can sit and think” were two of the comments made. There is good natural light in the resident’s rooms. The radiators are protected. Double rooms have privacy curtains. There are hand basins in all rooms, some residents have chosen to have locks on their doors and appropriate locks have been fitted. All rooms have a call bell and a smoke detector. Upstairs windows have been fitted with safety bars. The Lodge I55 S27322 The Lodge V224063 280405 Stage 4.doc Version 1.30 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 28 & 30 The home needs to increase the number of staff who have undertaken NVQ training. The home has a recognised Induction and Foundation Training EVIDENCE: Based on the information provided there is 1 member of staff who has NVQ level II, 1 member of staff is undertaking NVQ II, and one member of staff who has NVQ level III. On this basis the Manager needs to continue encouraging staff to undertake NVQ training. The Manager has completed the D32/33 Assessors Award, and the Management of Care 325/3. The home now has a recognised induction and foundation training and the documents for this were seen. Other training provided which enables staff to perform their tasks with the skills required includes Fire Prevention Training, Manual Handling, use of hoists, Health and Hygiene, Health and Safety. All staff have had First Aid training. Based on this information the home is developing an ethos of training which bodes well for the care of the residents. The Lodge I55 S27322 The Lodge V224063 280405 Stage 4.doc Version 1.30 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34, 36 & 37 The home is well run. The home has detailed professional accounts to safeguard residents’ finances. All staff receive supervision to ensure consistent monitoring and development. The home has a wide range of polices and procedures which are designed to safeguard the best interests of residents. The Lodge I55 S27322 The Lodge V224063 280405 Stage 4.doc Version 1.30 Page 18 EVIDENCE: The home has undertaken a survey of the services it provides, but has not yet collated this; it is the Manager’s intention to do so. The home has purchased documentation from the Mulberry Trust, which is of a very high standard. The Manager has had contacts with Norfolk Link with regard to Quality Assurance. It is the Manager’s intention to pursue enquiries, which will eventually lead to the home obtaining a recognised Quality Assurance Award. The home has detailed professional accounts, which were seen, which show the home to be financially sound. The home has a wide range of employment documentation that has been developed by the Manager that is of a high quality, this documentation was seen. The home’s employment procedures and practice are of a high standard. and this ensures that only suitable staff are employed and that the care and safety of residents is protected. The Manager is commended for this work. All staff receives supervision, which is carried out by the Manager. The supervision is planned and recorded. The supervision documents were seen, the Manager designed them, they are well designed, and set out documents. This ensures that there is a consistent system of monitoring and development of staff. During this inspection a wide range of documentation was seen. The content of this documentation improves in quality year on year due to the hard work of the Manager and the members of the care team. All documentation is kept secure, and only authorised persons have access to it. The Lodge I55 S27322 The Lodge V224063 280405 Stage 4.doc Version 1.30 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 2 x x x x 3 x x STAFFING Standard No Score 27 x 28 2 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 2 3 x 3 3 x The Lodge I55 S27322 The Lodge V224063 280405 Stage 4.doc Version 1.30 Page 20 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard Regulation None Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard 9 19 28 Good Practice Recommendations It is recommended that the Controlled Drug Cupboard is fitted as soon as possible. It is recommended that the work on the ground floor is completed as soon as is possible. It is recommended the the Manager continue to encourage staff to undertake NVQ training. The Lodge I55 S27322 The Lodge V224063 280405 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection 3rd Floor Cavell House St Crispins Road Norwich NR3 1YF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Lodge I55 S27322 The Lodge V224063 280405 Stage 4.doc Version 1.30 Page 22 - 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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