Inspection on 29/10/07 for The Lodge

This inspection was carried out on 29th 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 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 01/11/06

The Lodge 16/02/06

The Lodge 06/10/05

The Lodge 21/01/05

The Lodge 14/10/04

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

CARE HOMES FOR OLDER PEOPLE The Lodge Copdock Ipswich Suffolk IP8 3JD Lead Inspector John Goodship Unannounced Inspection 29th October 2007 09:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Lodge DS0000024437.V353767.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Lodge DS0000024437.V353767.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Lodge Address Copdock Ipswich Suffolk IP8 3JD Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01473 730245 T/F 01473 730245 mick@geminicarelodge.orangehome.co.uk Gemini Care Limited Mr Michael Bailey Care Home 44 Category(ies) of Dementia - over 65 years of age (44) registration, with number of places The Lodge DS0000024437.V353767.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st November 2006 Brief Description of the Service: There has been a residential home caring for older people in the present building for many years. The current owner, Gemini Care Homes Ltd (a company owned wholly by Mr Abbas), was registered in December 1997. The Home is a large country house set in its own mature gardens, situated on the main road running through the village of Copdock. The County Town of Ipswich is a few miles to the north and the home is near to the main A12 road from London. The current owner carried out an extensive refurbishment of the accommodation in 1998, and in late 2005 completed two new ground floor wings providing spacious accommodation to a very high standard. At the same time a further refurbishment, and expansion of the communal areas was carried out, with more separate communal areas being created, and at the same time reducing the number of shared bedrooms. The home now caters for 44 residents, and specialises in caring for older people with dementia. The range of fees quoted in the Service Users’ Guide at the date of this inspection was £534.29 to £700.00 per week. The Lodge DS0000024437.V353767.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection visit was unannounced and covered the key standards which are listed under each outcome group overleaf. This report includes evidence gathered during the visit together with information already held by the Commission. The inspection took place on a weekday and lasted eight hours. The manager was present throughout, together with staff on the morning shift and, later, those on the late shift. The inspector toured the home, and spoke to some of the residents, four relatives who were visiting, and the staff, two in private and others in the course of their duties. The inspector also examined care plans, staff records, maintenance records and training records. A questionnaire survey was sent out by the Commission to residents, relatives and to staff. No resident was able to complete the form. However nine relatives and four staff did respond. Their answers to the questions and any additional comments have been included in the appropriate sections of this report. For the first time, the Commission had asked all homes to complete this year an Annual Quality Assurance Assessment (AQAA) form. The information which the manager of this home included in their assessment has been used to inform and support other evidence in this report. What the service does well: The home provides full information to those considering coming to live there, including informative booklets from external bodies. The home provides a very homely and relaxed environment for residents who have complex and long term care needs. Accommodation provided is of a good standard which is well maintained, and benefits from the recent extension. Comments, made in comment cards and at the time of the inspection, indicated that family members appreciated the support offered to them by the staff and management of the home. They also praised the friendliness and kindness of the staff. Social activities are well-managed, creative and provided daily variation and interest for people living in the home. Relatives and friends are made welcome. Menus provide good nutrition and residents are supported where necessary to eat meals at their own pace. The Lodge DS0000024437.V353767.R01.S.doc Version 5.2 Page 6 The home is usually able to continue to care for residents to the end of their lives. Relatives have said how much this is appreciated by them, and is the wish of residents that they should not be moved away. The assessment process, and the staff, demonstrate that the home is skilled in the care of people with dementia. This is evidenced by the outcomes for residents which were seen on the visit, and are described by their relatives. What has improved since the last inspection? The home has improved the procedures relating to the employment of staff. As identified in the previous inspection report, all staff employed by the home are now be subject to a POVA check before commencing duties. The home now ensures that no prospective resident is admitted without an individual assessment of need being carried out by a member of the home’s staff, and in the case of local authority placements, assessments by the named assessor. The medication trolley is now locked when the carer is away from it to ensure the safety of the residents. Both shared rooms are now equipped with a privacy screen. A designated hand-washing sink has been provided in the laundry room, which is located in an outbuilding to the rear of the building, in order to further promote effective infection control procedures. The emptying, cleansing and storage of commode pots has been reviewed to ensure proper infection control. All staff now receive a structured one-to-one supervision session at least six times a year for the identification of training needs and the monitoring of care practices. All visitors are required to sign in, both for the security of residents, and to comply with evacuation policy in the event of a fire. The fire alarms and emergency lighting are now tested weekly and recorded. New fridges and freezers have been installed in the kitchen. The Lodge DS0000024437.V353767.R01.S.doc Version 5.2 Page 7 What they could do better: Whilst outcomes for service users are generally very positive, the manager agreed to review other formats of care planning particularly focussed on people with dementia. This had been an objective stated in the AQAA. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Lodge DS0000024437.V353767.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Lodge DS0000024437.V353767.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5,6. Quality in this outcome area is good. Prospective residents can be assured that they will have sufficient information to decide if this home is where they wish to live. The home will also collect information to assure the person that the home can meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had a Statement of Purpose and Service User Guide as required by Regulation 4 and 5 of the Care Homes Regulations 2001. The inspector was shown a copy of this combined document. It was up-to-date and included the current range of fees. The local authority had a block contract with the home for 27 beds. The placement contract issued by the home included details of the terms and conditions. It was noted that residents placed via the local authority did not The Lodge DS0000024437.V353767.R01.S.doc Version 5.2 Page 10 receive a placement contract via the home although details regarding terms and conditions were contained within the Service User Guide. It was noted that in one case of referral from home, where the referral was made by the family, the pre-assessment form had only been finally completed on the day of admission. The manager explained to the inspector that it was not always possible to confirm that a person referred from home had been diagnosed with dementia. The home did not have access to their medical records at that stage. In contrast, in the case of another resident referred by social care services from hospital, the home had received assessments from the community mental health team and the hospital. These formed the basis of the home’s own assessment. The manager confirmed that there had been instances where the home had declined to admit a person, as their needs did not fit the home’s admission criteria. The manager explained that relatives were encouraged to visit the home beforehand to see how residents were cared for. The home also welcomed prospective residents to attend for a day if that was possible. The information pack for relatives, as well as including the Statement of Purpose, also included two booklets from the Commission for Social Care Inspection: “Choosing a care home”, and “Care homes for older people”. The home was able to evidence that they did not provide an intermediate care service. The Lodge DS0000024437.V353767.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11. Quality in this outcome area is good. Residents living at the home can expect to be provided with an individual care plan which sets out how their assessed needs will be met. Residents can also expect that their physical and mental health care needs will be met. Residents are protected by the home’s systems used for the administration of medication. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three care plans were examined. In each case an individual care plan had been produced which provided staff with clear guidelines on the assessed needs of individuals and the levels of intervention required to ensure that these needs were met. They were all prepared on a format which was sufficient to record all personal care and social activities. The inspector discussed with the manager how the social, psychological and emotional needs of a person with dementia could be identified, and staff given specific guidance on how to The Lodge DS0000024437.V353767.R01.S.doc Version 5.2 Page 12 respond to various situations that they may meet. The manager agreed to review other care planning formats and assess their suitability for the home. All three care plans recorded the initial assessment of care needs under several headings such as mobility, continence, moving and handling, and nutrition. Care plans seen evidenced that residents were supported and enabled to access community health resources and services such as GP surgeries, district nursing services, opticians and chiropody. All visits to service users by health and community services were recorded on a multi-disciplinary care planning sheet. Clinical guidance and support was derived from the NHS community mental health team. The home used the Malnutrition Universal Screening Tool and there were records of monthly weight checks in the care plans. The home had a weighing chair to allow all residents to be weighed regardless of their mobility. The manager explained that the policy was to refer any resident to their GP if they showed a weight loss. All three care plans included an individual risk assessment and moving and handling assessment. The home was able to evidence that care plans were regularly reviewed and amended when individual needs or levels of dependency changed. These monthly care reviews were recorded, as was an annual medication review. The daily records were full and had information about the meals taken, any visitors, and activities which the resident had taken part in. Night records also contained precise information about the regular checks on residents. The residents had recently received their winter flu jabs from the district nurses. According to the manager, about 95 of the residents consented to the vaccination, or their relatives did. Consents were filed in the care plans. The manager explained that the home would always try to continue to care for a resident up to the end of their life if this was possible. He showed the inspector a letter from relatives of a recently deceased resident which said: “Thank you for caring for our relative in their last days. They wanted to stay at The Lodge and we are grateful that you were able to care for them to the end”. The manager said that the home was well supported by the two GP practices, with a weekly visit from a GP from each practice, and twice weekly visits from the district nurses. If a resident had a hospital appointment or needed inpatient care, a member of staff would accompany them to the hospital. This was good practice as it helped to reduce any confusion experienced by the resident in strange surroundings. During the inspection, the manager left for a short while to attend the funeral of resident. During the inspection, the systems and procedures used for the safe storage and administration of resident medication were examined and observed. The staff member responsible for the administration of medication on the shift was observed carrying out part of the mid-day medication round in the lounge. Medication was administered from a fit-for-purpose trolley, which was locked The Lodge DS0000024437.V353767.R01.S.doc Version 5.2 Page 13 each time the carer moved away. Medication was administered individually to each resident and the Medication Administration Record (MAR) sheets signed. Refused or spoiled medication was recorded on the MAR sheet and returned to the pharmacy on a monthly basis. The staff member administering medication had a good knowledge of how well and in what form individual residents accepted their prescribed drugs. They explained the various ways in which residents were supported and encouraged to take their medication. Systems used for the storage of Controlled Drugs were examined and found to be secure and appropriate, and accurate records of administration were maintained. Evidence was available to confirm that a weekly audit of resident medication and associated administration records was carried out. A sample check on stock levels showed that the balance of a drug remaining tallied with the number received and then administered. Observations throughout the inspection indicated that residents were treated with respect and their dignity maintained. Staff were observed several times moving a resident from wheelchair to recliner chair, ensuring that their dignity and privacy were respected by how they addressed the person, and ensuring that their clothes were properly arranged. Staff were observed to knock on bedroom doors before entering. All bedroom doors were fitted with privacy locks. All rooms, bar two, were offered for single occupancy and all nineteen bedrooms sited in the new extension had en-suite facilities, thus offering maximum privacy. During the environmental tour of the premises it was noted that both shared rooms had now been provided with a privacy screen. Four relatives who were visiting during the day were happy to speak to the inspector with their comments on the home. All said that they were content with the care. One resident said that they were well looked after but they would prefer to be at home. Their relatives gently reminded them how difficult it had been for the person living at home. The inspector spoke to two residents in the main lounge. They were both happy with their care, including one who had only recently been admitted. The Lodge DS0000024437.V353767.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Quality in this outcome area is good. Residents are offered many opportunities to participate in activities. They are supported to maintain family and other contacts. Residents’ nutritional needs are monitored, and they have a varied menu with safe catering procedures. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the inspection, the home was able to evidence that it placed a high importance on the provision of meaningful activities for residents. There were 27 residents seated in the main lounge during the morning. Music was playing quietly in the room and it was generally calm and quiet. However residents became more talkative and active after lunch. Eight residents with extra care needs were seated in the Quiet Room. All these people needed hoisting when moving, and support to feed. Two staff were assigned to this room. Five residents were in the Coach House which was situated across the yard from the rear door. They were watching TV, and appeared to be more independent than others. A senior carer was based in this part of the home. The Lodge DS0000024437.V353767.R01.S.doc Version 5.2 Page 15 One of the assistant care managers was the activities organiser. The programme for the month of November was displayed. It listed floor games, horse racing, reminiscence, flower arranging, card making, Christmas cake making, making doughnuts, and a visiting variety act. A religious service was held twice a month. On the afternoon of the inspection, a floor game was programmed. This was target bowls. The organiser was able to generate a good deal of interest and participation from residents, and from visitors. There was evidence of a high level of stimulation even for those not physically taking part. This was a very active and inclusive session. A relative wrote in their comment card: “ The staff are always trying to stimulate the minds of the residents and seem to get pleasure out of it when they respond.” The manager showed the inspector photo albums and biographies which were being created for residents in conjunction with their families as part of their reminiscence work, and as a guide for staff on interpreting residents’ feelings and interests. At lunchtime, most residents ate in the two dining rooms, apart from eight high dependency residents who were supported to have their lunch in the quiet room. The meal was mince, vegetables and potatoes. One person said they were put off the main course by watching two people on their table “messing with their food”. They asked for corned beef sandwiches, which were quickly made. They then chose to have the dessert of iced sponge and custard. The manager was asked why there was no choice of dishes on the menu. The manager said that most residents would forget what they had chosen even if they were shown photos of dishes. Staff would always suggest alternatives if a resident wanted something else. In the kitchen was a list of residents and their special dietary needs and the dishes which some residents would not eat. Eight out of the nine respondents to the relatives’ survey said that the home always or usually kept them up-to-date with important issues affecting their family member. One relative wrote: “If I am unable to visit, I know I can phone the home and speak to someone about the welfare of my family member”. Another relative wrote: “They are very good at contacting me at all times, for example after a fall or if the GP has been called”. The Lodge DS0000024437.V353767.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. Quality in this outcome area is good. Residents and their families are provided with sufficient information to enable them to make a complaint about the service or to raise any concerns they may have. Policies and procedures adopted by the home seek to protect residents from any form of abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had a complaints procedure which was included as part of the Service User Guide and was also sent out to service users along with the placement contract. A copy of the complaints procedure was also displayed within the home and therefore accessible to all visitors to the building. The home maintained a record of complaints received and had a form for complainants to use. However the home had received no complaints since the previous inspection in 2006. Seven of the nine comment cards returned by friends/relatives indicated that they were aware of the home’s complaints procedure. One said that they could not remember how to complain but they had never needed to. All of them said that the home had always responded appropriately if concerns had been raised. The home’s Whistleblowing policy was displayed on the notice board by the staff room. The Lodge DS0000024437.V353767.R01.S.doc Version 5.2 Page 17 The training of staff in the recognition of abuse to vulnerable people, and the action staff must take if they suspected it was happening, was covered, the manager said, at induction and during the NVQ Level 2 modules. Two staff who spoke to the inspector were able to talk knowledgeably about this issue and knew the route to take to raise their concerns. The Manager advised the Inspector that the service did not have any involvement in the administration of resident finances. As service users have a diagnosis of dementia, finances were usually administered by a family member, financial advocate or the placing authority. The Lodge DS0000024437.V353767.R01.S.doc Version 5.2 Page 18 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): 19,20,21,22,23,24,25,26. Quality in this outcome area is good. Residents living at the home can expect to be provided with accommodation, both private and communal, which is comfortable, homely, well maintained and appropriate to their needs and abilities. Residents can also expect to live in an environment which is clean and hygienic. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home was registered to provide accommodation for up to 44 older people who had a diagnosis of dementia. The home stood in extensive grounds and accommodation was sited on two floors both of which were accessible via a passenger lift. Two new wings were commissioned in December 2005 and provided an additional 19 bedrooms, all for single occupancy and with en-suite facilities. The home had reduced the number of shared rooms on offer, The Lodge DS0000024437.V353767.R01.S.doc Version 5.2 Page 19 although two still remained, enabling residents to share accommodation should they wish to do so. Only one shared room was now occupied as such. Some of the rooms were situated in the Coach House which was detached from the main building and was suitable for residents who were less dependant. A range of communal accommodation was available, including a large lounge and another smaller lounge for residents with higher dependency levels. The nineteen bedrooms provided within the new extension were spacious, furnished to a good standard with low level windows (fitted with restrictors) and under-floor heating. Bedrooms within the older part of the building were also comfortably furnished and maintained to a good standard of decorative order and repair. It was apparent that residents and their families had been encouraged to make their bedrooms as homely as possible with the addition of personal belongings, ornaments, plants and photographs. In addition to ensuite accommodation provided, the home had a sufficient number of communal bathrooms, with assisted baths and showers. Aids and adaptations were fitted around the home to aid mobility and handrails were provided in corridor areas. The home had installed a separate hand-washing sink in the laundry as required from the previous inspection. The inspector was shown the written procedure for the emptying, cleansing and storage of commode pots. The home appeared clean and tidy, and there were no unpleasant odours. The home employed dedicated domestic staff, and the cleaning rota was seen on the staff notice-board. A relative wrote: “The cleanliness of the home is very good”. The home had placed alcohol hand gels around the building for staff to use as a supplement to hand washing to prevent instances of cross-infection. The home had a large kitchen to the rear of the building. A kitchen cleaning rota was maintained which identified weekly and daily cleaning tasks. Replacement fridges and freezers had been installed since the previous inspections. It was noted that these were running within the correct temperature range. The daily record of temperatures was shown to the inspector. The Lodge DS0000024437.V353767.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. Quality in this outcome area is good. Residents living at the home can expect to be supported and cared for by a level of staffing which is appropriate and trained to meet their special and complex needs. Residents can expect that they will be protected by the home’s policy on recruitment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the day of the inspection, residents were being supported and cared for by six members of care staff. The home ensured that a minimum of one senior staff member was in attendance on each shift. This level of staffing continued until 9pm in the evening when four staff members were on duty providing “waking” night care. In addition to care staff, three domestic staff were on duty to ensure that the environment was maintained to a good standard of cleanliness. The home also employed kitchen staff who were responsible for the provision of residents’ meals. A comment card returned to the Commission by a relative reported that their family member was looked after and cared for exceptionally well. Another relative wrote that the staff were always friendly and welcoming. Another called them “patient and kind”. The family members of two residents spoken to The Lodge DS0000024437.V353767.R01.S.doc Version 5.2 Page 21 at the time of the inspection reported that they very much appreciated the care. The staff were described as very supportive to the family when their relative became a resident. The Inspector observed that a good rapport existed between staff members and residents. All the staff comment cards agreed there were enough staff rostered on each shift, although two commented that staff sickness could make things harder. The home had no staffing vacancies at the time of the inspection. The home was able to evidence that eight of the 23 care staff employed have achieved an NVQ qualification in either Level 2 or Level 3 in Care. An additional three care staff were currently undertaking an NVQ Level 2 in Care. The inspector examined the recruitment files for three care staff employed since the previous inspection. All of them provided evidence that a POVA check had been received before the person started work in the home under supervision. This had been a requirement imposed at the previous inspection. In the case of one person, who had started in August 2007, the full Criminal Records Bureau (CRB) certificate had not yet been received. Another person who was an overseas worker was also awaiting their CRB certificate. All other documentation for this person such as work permits were in the file. The files for all three staff held information on induction and other training where appropriate. The home used an induction format which covered the Skills For Care common induction standards, such as moving and handling, food hygiene, fire safety and health and safety. One of the three staff held an NVQ Level 3 and was also an accredited NVQ assessor. Other training records for the home’s staff were examined. Seven staff had completed training in the safe administration of medication. Moving and handling training was conducted by a qualified trainer from the other care home run by the provider. The home had arranged further training in Dementia Awareness with the Alzheimer’s Society and the next course was due to start shortly. Members of staff who spoke to the inspector confirmed the training that they had received including the training in dementia care. One person was able to describe instances where a resident became aggressive, and was knowledgeable about the physical and emotional reasons which could trigger this, and the action that staff should take to support the resident. The Lodge DS0000024437.V353767.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,37,38. Quality in this outcome area is good. Residents and relatives can expect the home to be well run, by competent staff. Their safety is assured by the home’s health and safety practices. A process of staff supervision protects residents by continually monitoring and improving the skills of the staff. The system of quality assurance, and the regular maintenance checks ensure that the home is safe. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspector checked that the requirements imposed at the previous inspection had been actioned. All had been. There was now a visitors’ book, The Lodge DS0000024437.V353767.R01.S.doc Version 5.2 Page 23 regular staff supervision, new refrigerators maintaining safe temperatures, and regular fire alarm and emergency lighting testing. The Manager of the home, who had been in post for five years, was registered with the Commission and had completed the Registered Managers Award in March 2005. The registered owner of the home visited the home at least once a week according to the manager. The home followed a planned quality assurance process. The owner visited several times a week and noted items for discussion or action. Although the owner recorded these visits, no copy was kept in the home to meet Regulation 26. The owner also conducted a quarterly quality review of the home using a scoring system, covering environment, care practices, staff, and management systems. Annual questionnaires were sent to families, the most recent being in the summer of 2007. Replies were positive about the home. The owner explained how a particular suggestion had been discussed with some families to see how it could be implemented. The home sent out newsletters quarterly to relatives. One relative wrote that they were made aware by the newsletter of forthcoming events and activities. A staff member confirmed that staff meetings were held regularly. The inspector examined the records of staff supervision sessions. These were held in each person’s file. Staff also confirmed these were taking place. The fire log recorded the weekly alarm and emergency lighting tests, and the fire drills. The last one was recorded in July 2007. There was an up-to-date Fire Risk Assessment. There were also general risk assessments for the home, mostly listed room by room. There was a special assessment to cover the pregnancy of a staff member. The Lodge DS0000024437.V353767.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 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 3 3 3 X 3 3 3 3 The Lodge DS0000024437.V353767.R01.S.doc Version 5.2 Page 25 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 Standard OP33 Regulation 26(4)c Timescale for action A record of the visits made under 30/11/07 this Regulation must be kept in the home. Requirement 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 DS0000024437.V353767.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Colchester Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Lodge DS0000024437.V353767.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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