Inspection on 01/12/05 for The Lodge Care Centre

This inspection was carried out on 1st December 2005.

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

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

Other inspections for this house

The Lodge Care Centre 02/05/07

The Lodge Care Centre 05/05/06

The Lodge Care Centre 04/02/05

The Lodge Care Centre 19/08/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Lodge, The Care Centre Bridge Street Killamarsh Sheffield Derbyshire S21 1AL Lead Inspector Ivan Barker Unannounced Inspection 1st December 2005 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 Lodge, The Care Centre DS0000002088.V270626.R01.S.doc Version 5.0 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. Lodge, The Care Centre DS0000002088.V270626.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Lodge, The Care Centre Address Bridge Street Killamarsh Sheffield Derbyshire S21 1AL 0114 2476678 0114 2476733 thelodge@highfield-care.com 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) Southern Cross Care Homes Limited Mrs Pam Brookes Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Lodge, The Care Centre DS0000002088.V270626.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1. To admit the service user named in The Notice of Proposal letter dated 16th July 2004, under the age of 65 years in the category of PD 25th July 2005 Date of last inspection Brief Description of the Service: The Lodge Care Centre is a purpose built home for 40 residents, with 20 places for service users receiving personal care and 20 places for service users receiving nursing care. The home is situated in Killamarsh, which is in the Derbyshire Area, but provides facilities for service users from the Derbyshire and Sheffield regions. Lodge, The Care Centre DS0000002088.V270626.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Only a limited number of the National Minimum Standards were examined at this inspection (with emphasis on several of the ‘key standards’), and the previous requirements. The persons present at the inspection were: Mr G Harowar, Acting manager. Mrs T Saunders, Regional manager. Within this inspection, which occurred over a four hour period, the inspectors toured the building relating to the previous requirements, spoke with service users, relatives and staff and examined some documentation. The information on the previous page regarding the registered manager is incorrect, as Mrs P Brookes has left the company. Mr G Harowar was the Acting manager. During the inspection Mr Barker, Inspector, was accompanied by Mrs D Bate Inspector, as part of a shadowing exercise. What the service does well: What has improved since the last inspection? The company has complied with the majority of the requirements, only the fitting of 3 locks was outstanding. Lodge, The Care Centre DS0000002088.V270626.R01.S.doc Version 5.0 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. Lodge, The Care Centre DS0000002088.V270626.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lodge, The Care Centre DS0000002088.V270626.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3 Accurate assessments will ensure that the home has sufficient information to be aware of the service user’s needs prior to admission EVIDENCE: The Acting manager informed the inspectors that the home received service users’ assessments from the Social Services Care managers, however on some occasions the assessments were not always delivered prior to admission. The manager or senior staff prior to admission to the home assessed all service users. The inspectors observed these documents. Lodge, The Care Centre DS0000002088.V270626.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These key standards were previous assessed at the last inspection. Lodge, The Care Centre DS0000002088.V270626.R01.S.doc Version 5.0 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13 and 14. Various activities were organised within the home, which would provide stimulation to service users and enhance their quality of life. EVIDENCE: There was an Activities co-ordinator who was employed for 22 hours per week. The Acting manager informed the inspector that she worked 4 days a week on a flexible basis. The inspectors were shown evidence that there was a programme of activities and outings were planned and Christmas celebrations were being organised. The Acting manager identified that the Activities Co-ordinator was new in post and was yet to create individual records of the service user’s participation in the activities and outings, which was part of the company’s documentation. Service users were able to access the local village, being accompanied by staff or their relative or visitor. A minibus was available to service users. This vehicle was shared by several of the homes within the company. Lodge, The Care Centre DS0000002088.V270626.R01.S.doc Version 5.0 Page 11 The inspector discussed with service users the activities and outings. All the service users identified that they were satisfied with the programmes provided and commended the new Activities co-ordinator. The Acting manager also commended her efforts. Lodge, The Care Centre DS0000002088.V270626.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. Relatives and visitors would not be able to contact the relevant persons, as the information on the complaints procedure was incorrect. As far as could be established the home took complaints seriously and acted upon the issues. Some staff received training, which should make them more aware of Adult Protection. EVIDENCE: The complaints procedure was displayed, and did not contain the necessary information. It identified the National Care Standards Commission and the previous owners of the company. The Acting manager identified that the complaints procedure would be amended without delay. The complaint book was examined and no complaints were outstanding. No one during the inspection asked to see the inspectors to voice any complaints. However some areas of concerns were raised with the inspectors and these will be covered within other sections of the report. The inspector was shown evidence, by the provision of training records that some training in Adult Protection had occurred. However some staff had not received adult protection training. The managers offered the inspectors a timescale of three months to address this issue. Lodge, The Care Centre DS0000002088.V270626.R01.S.doc Version 5.0 Page 13 On discussing the policies and procedures of Adult Protection, the Acting manager had problems locating the documents. The inspectors discussed the importance of having these documents readily available, particularly out of hours so that they would always be available to senior staff. Lodge, The Care Centre DS0000002088.V270626.R01.S.doc Version 5.0 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 the following standard(s): Standard 24 An environment had not been provided which met the minimum standards. EVIDENCE: The key standards were monitored on the previous inspection and subsequent requirements were monitored at this inspection. Locks had been fitted to all bedroom doors except for 3 bedrooms, which were rooms 36, 37, and 38. All other requirements had been addressed. Lodge, The Care Centre DS0000002088.V270626.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 28,29 and 30. The necessary documentation designed to protect the service users were in the staff files. Staff had received moving and handling and fire training. An up to date workforce will contribute to the delivery of care. Should the staff receive additional training this will also benefit the service users. EVIDENCE: On the examination of 3 staff files, all contained the information required within Schedule 2 and 4. On examination of the staff training records the inspector established that the staff had received their annual Moving and Handling training, and Fire training. However, these documents were difficult to reference. The Acting manager agreed to review the file. Through discussions with staff it was established that staff would appreciate the opportunity to undertake specialist training to widen their skills, e.g. for care staff to undertake some dementia awareness training and for trained staff to keep up to date with new progress in the medical and nursing matters. Several staff confirmed that they had undertaken NVQ training. Lodge, The Care Centre DS0000002088.V270626.R01.S.doc Version 5.0 Page 16 During the inspection the inspectors discussed with staff and relatives the staffing levels, training, etc and several comments were made that indicated that at times staff felt pressured and stretched, indicating that sometimes service users had to wait to have their personal needs met. On examination of the information provided at the last inspection it was established that staffing was as follows: On the am shifts, there were 1 qualified nurse and 5 care assistants. On the pm shifts, there were 1 qualified nurse and 4 care assistants. On the night shifts, there were 1 qualified nurse and 3 care assistants, or 1 qualified nurse and 2 care assistants. In addition there was the manager, who was supernumerary, and an activities co-ordinator who worked 10.00 to 16.00, 4 days a week. Caring for 32 service users (14 receiving nursing care, and 18 receiving personal care.) On this inspection the inspectors were informed that staffing levels were as follows: On the am shifts, there were 1 qualified nurse and 4 care assistants. On the pm shifts, there were 1 qualified nurse and 4 care assistants. On the night shifts, there were 1 qualified nurse and 2 care assistants In addition there was the Acting manager, who was supernumerary, and an activities co-ordinator who worked 22 hours, over 4 days a week. Caring for 32 service users (14 receiving nursing care, and 18 receiving personal care.) The inspectors were informed that staffing levels were increased, if service user levels were above 32. There were 32 service users on both inspections, but the figures above show that there had been a reduction in the staffing levels. The inspectors discussed with the managers the importance of meeting dependency needs and they agreed to review the needs and staffing levels. The managers indicated that some recruitment was taking place. The inspectors will monitor the staffing at the next inspection. Lodge, The Care Centre DS0000002088.V270626.R01.S.doc Version 5.0 Page 17 Regarding Standard 30, the shortfall within Adult protection training was addressed within Standard 18. However both standards were awarded a score of 2, for the purpose of this report. Lodge, The Care Centre DS0000002088.V270626.R01.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,33,35,36,38. The management of the home does comply with the requirements of the Care Homes Act. Quality assurance systems will assist the managers and company to measure the home against expected outcomes. EVIDENCE: A registered manager was not in post. An Acting manager had recently been appointed and has yet to be registered. He was aware of the process of registration and informed the inspectors that he would be making a formal application in the very near future. Comments from staff and relative regarding the manager were very positive about his management style, e.g. ‘he was friendly, always speaks and checks everything is alright’. Lodge, The Care Centre DS0000002088.V270626.R01.S.doc Version 5.0 Page 19 The company had quality assurance systems, which were implemented by both the Acting manager and the Regional manager. The Regional manager identified that as part of the quality assurance of the company they obtained the views of service users and relatives. However, this had yet to occur within the home and was planned for February. Although some supervision records existed for care staff, staff indicated that they did not have appraisal and supervision on a regular basis. There were no supervision records available for qualified staff. The managers recognised that considerable improvements were needed to meet this standard and expressed their commitment to rectify the problem. Regarding the service users’ personal monies the home operated a basic credit and debit system. Regulation 26 visit occurred and there was documentary evidence to support this. As far as could be established there were no health and safety issues except if any were raised with the previous sections of the report. However, it was noted in the accident book that there had been 15 falls in the previous month. The inspectors discussed this factor with the managers, who informed them that there were particular individual service users who had attempted to walk unaided, and this had lead to the number of falls. The Acting manager identified that these service users had had their care plans and risk assessments reviewed. Staff meeting minutes indicated that this matter had been raised with staff and the home had a monitoring system and will be developing strategies to reduce falls. Lodge, The Care Centre DS0000002088.V270626.R01.S.doc Version 5.0 Page 20 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 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 X X X X X 2 X X STAFFING Standard No Score 27 X 28 X 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 2 X 3 Lodge, The Care Centre DS0000002088.V270626.R01.S.doc Version 5.0 Page 21 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 OP16 Regulation 22 Requirement The registered person must ensure that information is available to service users and relative of where to make a complaint and to whom to complain. The registered person must ensure that staff receive adequate training. The registered person must ensure that the 3 remaining bedrooms are fitted with locks. The registered person must appoint a registered manager. This person must undertake the ‘fit person’ process. The registered person must ensure that staff supervision of all staff occurs, six times a year. Timescale for action 01/01/06 2 3 4 OP18OP30 OP24 OP31 18 23 8,9 01/03/06 01/03/06 01/03/06 5 OP36 18,19 01/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Lodge, The Care Centre DS0000002088.V270626.R01.S.doc Version 5.0 Page 22 No. Refer to Standard Good Practice Recommendations Lodge, The Care Centre DS0000002088.V270626.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Lodge, The Care Centre DS0000002088.V270626.R01.S.doc Version 5.0 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!