Inspection on 02/05/07 for The Lodge Care Centre

This inspection was carried out on 2nd May 2007.

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 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 Care Centre 05/05/06

The Lodge Care Centre 01/12/05

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 The Lodge Care Centre Bridge Street Killamarsh Sheffield Derbyshire S21 1AL Lead Inspector Susan Richards Key Unannounced Inspection 2nd May 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 Care Centre DS0000002088.V335615.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 Care Centre DS0000002088.V335615.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Lodge 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 vacant post Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40), Physical disability (2) of places The Lodge Care Centre DS0000002088.V335615.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Southern Cross Care Homes Limited is registered to admit to The Lodge Care Centre persons within the following categories: Old Age, not falling within any other category (OP, N) 40 Physical Disability (PD) 2 persons aged 50 and above The maximum number of persons to be accommodated at The Lodge Care Centre is 40 5th May 2006 2. Date of last inspection Brief Description of the Service: The Lodge Care Centre provides for up to forty older persons who may require personal and nursing care and including two persons aged fifty years and above with physical disabilities. It is located within the village of Killamarsh, which is located within Derbyshire on the border of South Yorkshire and the boundary of Sheffield. It is a purpose built home providing a range of facilities, including all single room accommodation, seven of which have en suites. There is a choice of lounge and dining rooms, including a quiet lounge and also kitchenette areas, which service users who are able can access to make drinks and snacks. There are four assisted bathrooms, including specialist bathing and one shower room, together with suitable toilet facilities. Disabled access is provided to all parts of the home, which service users may access, together with suitable aids and adaptations to assist those service users, who may have physical disabilities, including handrails, grab rails and a nurse call system throughout. There is a small garden area to the rear of the home, which has a seating area. Kitchen and laundry services are centralised. There is an acting manager in post who is supported by an administrator and a team of nursing, care and hotel services staff, together with external management support. The range of fees charged by the home as detailed in the pre-inspection questionnaire completed by the acting manager on 13 April 2007 are as follows: £330.00 to £445.00 per week for those who receive personal care. £430.00 to £550.00 per week for those who received nursing. Fees are determined in accordance with individual’s assessed needs and also via contracts between the home and the relevant social services departments for those who are funded via local authority arrangements. The acting manager advised that information for service users (and their The Lodge Care Centre DS0000002088.V335615.R01.S.doc Version 5.2 Page 5 representative) regarding how to access the home’s inspection report is provided within the service user guide, although this was not available. . The Lodge Care Centre DS0000002088.V335615.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection report has been collated using the following: Current and up to date information the Commission holds about the home, including the last key inspection report of May 2006 and a random inspection visit in September 2006. Information provided by way of a pre-inspection questionnaire completed by the acting manager. Written feedback provided by four service users in response to our questionnaire survey from a total of thirty five sent out. Information collected during the site visit for this inspection, which included case tracking as part of the methodology. This involved the sampling of a total of three service users accommodated whose care and service provision was more closely examined. Discussions were held with those service users as able, together representatives as available and also other service users about the care and services they receive. Their care planning and associated care records were also examined and their private and communal facilities inspected. Discussions were also held with staff about the arrangements for care delivery and also for staffs’ recruitment, induction, deployment, training and supervision What the service does well: What has improved since the last inspection? The Lodge Care Centre DS0000002088.V335615.R01.S.doc Version 5.2 Page 7 The acting manager at that time did undertake the fit person process and was approved as registered manager (although no longer works at the home). Medicines records are properly maintained. There are clear arrangements in place to determine and plan for staff training. 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 summary of this inspection report can be made available in other formats on request. The Lodge Care Centre DS0000002088.V335615.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 Care Centre DS0000002088.V335615.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, 3 & 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users needs are reasonably well met, although this may not always be in accordance with their preferred routines and lifestyle preferences. EVIDENCE: Discussions were held with service users case tracked about the arrangements for their admission and their individual needs and how these were met. Their individually recorded needs assessment information was also examined. Two of the service users were unable to recall whether they were provided with information about the home prior to their admission, one said they had been The Lodge Care Centre DS0000002088.V335615.R01.S.doc Version 5.2 Page 10 given a ‘glossy brochure’ although couldn’t recall where this was or any of the contents of this. Of the four questionnaire surveys returned from service users (or their representatives) two said that received enough information about the home before they moved in and two said they did not received enough and would have preferred to know more. The home’s statement of purpose and the service user guide were not available at the time of the inspection visit to the home. The acting manager said that these had been revised and updated and were being republished and would be provided as soon as possible. She also advised that the service user guide was being made available in audio-tape and compact disc format. These will be further assessed at the next inspection of this service. Written needs assessments for each of those service users were generally well recorded and up to date, although information regarding individual daily living routines and lifestyle preferences was sometimes lacking. For example, regarding social care and activities interests and preferred bathing routines. Where service users were admitted through social services care management arrangements, copies of the needs assessment and care plan summaries were provided by them. Discussions held with staff indicated that they were fully conversant with the individual needs of those service users case tracked. Service users and their representatives felt that their needs were generally well met and expressed overall satisfaction with the care they received. However, service users were not always asked about their preferred routines, for example in relation to bathing but felt that staff may not always be able to accommodate these and were happy to ‘fit in’ with the routine of the home. The home does not provide for intermediate care. The Lodge Care Centre DS0000002088.V335615.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): NMS 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users health care needs are met and they are treated with respect. EVIDENCE: The written care plans of service users case tracked were examined and the arrangements for their care discussed with them. Written care plans were formulated within a framework of risk assessment and were up to date with regularly recorded reviews. They were reflective of recognised guidance concerned with the care of older persons. Service users had not seen their care plans and they were not routinely agreed with them or signed by them. Although the relative of one service user had been involved in aspects of their care planning and agreement with on behalf of the service user who was too ill to do so. The Lodge Care Centre DS0000002088.V335615.R01.S.doc Version 5.2 Page 12 A written notice was posted in the reception area advising of access to care plans and requesting relatives to sign them where appropriate on their relatives’ behalf. Access to outside healthcare professionals for the purposes of specialist, general and routine health care screening was suitably accounted for and service users spoken with (or their representatives where appropriate) knew about their particular arrangements. For one of the service users case tracked their nutritional needs assessment review details indicated the need for referral to a dietician, although there was no record as to whether this had been undertaken. The acting manager advised that this had been done. Wound care for this service user was also clearly recorded and included accessing specialist advice from an outside health care professional in respect of this. Of the four questionnaire surveys returned, one said they always received the medical support they needed, one said usually and two sometimes. The Inspector was unable to follow this up with individuals, as supporting comments/information was not given and the returns were anonymous. At the last key inspection of this service serious concerns were raised in respect of medicines recording. A further visit was carried in September 2006 when it was established that these records were properly completed with no omissions observed. The arrangements for the management and handling of service users medicines were examined during this inspection visit via case tracking. These were satisfactory. There were no service users who managed their own medicines, although there was a written policy in place in the event of this, which included an appropriate risk assessment. Two of the service users case tracked was unable to retain and administer their own medicines due to their level of need and capacity to do so. The third service users said that she was asked, but preferred for the home to manage these on her behalf. Lockable storage facilities were routinely provided in each service users own room. Service users spoken with said that staff treated them with respect and that their privacy and dignity was maintained. Comments were received (including those from relatives) included the following: “Staff are very good, they always try to make time for me and are polite.” “Staff are usually there to help me and are kind.” “Staff are always approachable, they have a good manner with residents.” The Lodge Care Centre DS0000002088.V335615.R01.S.doc Version 5.2 Page 13 Discussions with staff and examination of training records, including plans indicated access to training concerned with the health care needs of service users, including some planned extended role training for nurses working in the home. Three of the four surveys returned said that staff always listened and acted on what they said, although one person (responding on behalf of a service user) felt that not all staff listened. The Lodge Care Centre DS0000002088.V335615.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): NMS 12, 13, 14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Activities are routinely organised for service users and they receive a nutritious and balanced diet. However, the development of opportunities to maximise their capacity to exercise choice with regard to their daily living arrangements, social and leisure activities and meals may increase their sense of autonomy and control over their lives. EVIDENCE: Needs assessment information recorded with regard to the social care needs of service users, together with their known routines of daily living and lifestyle preferences was not always fully recorded. Service users and their representatives said that activities were organised in the home, but these were not as extensive or varied as in the past. Staff also expressed this view. Questionnaire survey returns also reflected this. The Lodge Care Centre DS0000002088.V335615.R01.S.doc Version 5.2 Page 15 Comments were also raised about the garden, regarding its inaccessibility, unsafe and uneven patio and drabness/lack of planting and substantial seating. One service user case tracked said she had been a keen gardener and liked to sit outside whenever appropriate. Although this was recorded within her care records, she said she had not done so since her admission a few weeks previously. This service user had also expressed a wish to go into the village from time to time. This had also not occurred. The service user felt that this was possibly due to a lack of staff time/resources. Another service user who was case tracked who was nursed in their own room due to recent changes in their condition and their level of need felt that staff did not have time to engage in one to one activities with her as much as they were too busy. The home employs an activities co-ordinator on a part time basis. On the day of the inspection visit, a game of bingo was organised in the upstairs lounge during the morning and in the down stairs lounge during the afternoon. Care staff felt that they were often too busy to assist the activities co-ordinator or to spend time with residents with regard to social stimulation and interaction. Information regarding activities was provided in the home and also detailed in the pre-inspection questionnaire completed by the acting manager. Activities include crafts, quizzes, reading, dominoes, bingo, chair based physical activities and hairdressing. The newly appointed acting manager had re-instigated the resident’s committee and minutes of those meeting were kept. Library services were also being re-instigated to include the provision of large print books to assist service users with sight difficulties. The Inspector was also advised of plans to develop access to the local and extended community for service users via company and community transport and also to enable two service users who wished to attend a local luncheon club. Church services are also organised on a monthly basis, which many service users enjoy. There were no service users accommodated with diverse cultural or religious beliefs/needs. Information was provided in the home and openly displayed regarding multi-cultural faiths and beliefs in accordance with various religious calendars. All service users spoken with said they were able to have visitors at any time they choose and that they were able to see them in private if they wished. There was no service users accommodated who solely handled their financial affairs. The manager advised that many had private arrangements, although the home did safe keep and handle personal monies on behalf of some service users. (See the Management section of this report). The Lodge Care Centre DS0000002088.V335615.R01.S.doc Version 5.2 Page 16 Information leaflets were displayed in the main reception area regarding how to access advocacy services. Service users spoken with said that overall they enjoyed the meals provided in the home, although comments were made by some regarding the lack of choice at tea time, which was said to consist of a variety of sandwiches each day with little else in terms of a choice. Staff felt that improvements were needed in terms of the provision of soft diets at tea-time for those service users who required their food presented in this way. Menus did detail sandwiches most days, together with a warm alternative, which was usually soup and included other items such as quiche, sausage rolls, cheese on toast and sardines on toast. The organisation and serving of a meal was observed during the inspection. This was well organised and service users received the assistance they required in the environment of their choice and were presented with alternatives on the menu. The Lodge Care Centre DS0000002088.V335615.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): NMS 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and their representatives know how to complain and are protected from abuse. EVIDENCE: There is a written complaints procedure for the home, provided in standard type format, which is openly displayed in the reception area, together with a suggestions box. The acting manager advised that the procedure was to being revised in order to update the contact details as to who to complain to, given the management changes in the home. She had also commenced a weekly ‘surgery’ for service users and their families and representatives, which was advertised in the home and aimed to give regular opportunity for individuals to raise any queries, views or concerns they may have. Service users spoken with said they knew how to complain and the questionnaire surveys returned from service users and/or their representatives all indicated that they knew how to complain. The Lodge Care Centre DS0000002088.V335615.R01.S.doc Version 5.2 Page 18 General information regarding the number of complaints received by the home over the last twelve months was provided in the pre-inspection questionnaire completed by the acting manager. These were discussed with her and the home’s written records inspected in relation to these. Five of the seven complaints were substantiated, one was partially substantiated and one, which was investigated via local joint agency adult protection procedures, was not upheld. All are satisfactorily resolved. Staff training and updates are provided for all staff with regard to recognising and responding to abuse and written procedures are in place in respect of these. Staff spoken with was conversant with their responsibilities with regard to handling complaints and recognising, responding to and report the abuse of any service user. Staff training is also provided for staff with regard to dealing with aggression. The Lodge Care Centre DS0000002088.V335615.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): NMS 19, 20, 21, 22, 24, 25 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall the home provides a well-maintained internal environment, which is comfortable and suits service users needs. However, the garden area does not. EVIDENCE: The private and communal accommodation of service users case tracked was inspected. All internal areas seen were clean and hygienic, well furnished decorated and equipped in accordance with the needs of service users. Overall, there are suitable arrangements in place for the ongoing repair and renewal of the home, although the patio area to the rear garden and the access pathway to the home were uneven and a potential hazard for service The Lodge Care Centre DS0000002088.V335615.R01.S.doc Version 5.2 Page 20 users. The rear garden was not attractive or inviting, with little in the way of planting or seating. Some service users and their representatives commented about the rear garden aspect of the home, including those who returned a written survey, and felt that this required attention and development to enable more independent and safety of access and to provide an attractive garden. There were no recorded accidents or falls in the garden area, however, this was not accessed by service users. The acting manager advised that works were due to commence on the entrance pathway to rectify the uneven paving. Two questionnaire survey returns commented on the need to replace some curtains in the home, which were not fitted properly. Some of these were replaced at the time of the site visit. There is a choice of lounge and dining rooms throughout the home and smaller group living is promoted. There are small kitchen areas providing drinks making facilities, which service users can access with supervision as required. Service users occupied various areas of the home at the time of the site visit, including their own rooms, which were very well personalised and equipped in accordance with their assessed needs. Bathing and toilet facilities were clean, well equipped and accessible and include specialist bath facilities, although the shower room was not accessible to some service users due to its design. The acting manager who advised of plans to replace this in order increase its accessibility for service users. The home provides all single room accommodation, seven of which have ensuites. Service users spoken with, (and their representatives) expressed overall their satisfaction with their environment, which they said was comfortable and suited their needs (excepting the garden area). The doors to service users own rooms were fitted with suitable locks and also door-knockers and letter boxes. All areas of the home were well ventilated, warm and well lit. Some service users and their representatives said that there were problems with the heating during the winter months. Satisfactory maintenance details regarding hot and cold water and heating systems and gas appliance was provided by way of the pre-inspection questionnaire. There are separate laundry facilities, which are clean and suitably equipped, together with separate sluice facilities. The acting manager advised that there had been difficulties with one dryer, which was damaging some clothing. This was out of action and a replacement had been ordered. The Lodge Care Centre DS0000002088.V335615.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): NMS 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are suitable arrangements in place for the recruitment, induction, training and deployment of staff in the home. EVIDENCE: Details of staff employed and the arrangements for their recruitment and training were provided by way of the pre-inspection questionnaire. The arrangements for their deployment in the home were discussed with the staff, some service users and representatives and duty rotas examined. Feedback was also received regarding staffing arrangements and staff availability in the questionnaire surveys returned. All service users said they usually received the care and support they needed, with one person surveyed indicating that this was only sometimes. Many felt that staff were very stretched and did not always have sufficient time, although felt that their basic personal and health care needs were being met. Staff feedback was also reflective of these views. However, in addition staff felt more confident now a new manager was appointed. They have been without a consistent registered manager for some time (see management section of this report). The Lodge Care Centre DS0000002088.V335615.R01.S.doc Version 5.2 Page 22 The new manager had re-instigated staff meetings and a system of individual staff supervision was in the process of being rolled out, with records kept. There were thirty-five service users accommodated, including 11 receiving nursing care. Details of their individual dependencies were included in the preinspection questionnaire. Duty rotas indicated that there was usually one registered nurse and five care staff on duty throughout the day and one registered nurse and three care staff at night. The manager’s hours (also a registered general nurse) and those of the activities co-ordinator and hotel services staff cover are additional to these. Care staff hours provided (not including registered nurses) meet with residential forum guidance. The arrangements for staff recruitment, induction and training were also discussed with staff and associated records were examined, including the personal records of four of the most recent staff starters. A total of sixty percent of care staff have achieved at least NVQ level 2. The manager advised that one care staff was now undertaking an NVQ level 3 and that funding arrangements were being reviewed to ascertain access for other care staff who may wish to undertake this level. A further four care staff were also due to commence NVQ level 2 and also some hotel services staff. The home operates a thorough recruitment procedure, confirmed via discussions with staff and examination of records. A staff training matrix and plan was established. Staff felt that access to training was very good and discussions with them and examination of records confirmed that these arrangements are satisfactory. The Lodge Care Centre DS0000002088.V335615.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): 31, 33, 35 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users’ health, safety and welfare are reasonably well promoted and protected, although they are not always effectively consulted with, which may compromise their best interests. EVIDENCE: At the last key inspection of this service a requirement was made for a registered manager to be appointed for the home and the then acting manager to undertake the fit persons process. A random inspection carried out at the home in September 2006 detailed that this manager had submitted their application as registered manager, which was approved. However, this The Lodge Care Centre DS0000002088.V335615.R01.S.doc Version 5.2 Page 24 manager has since been moved to another home with the group and a new acting manager appointed who commenced on 05 March 2007. To date she has not submitted a registered manager’s application to the Commission, but said that this was in hand. During discussions with the acting manager she demonstrated an awareness of the need to keep up to date with practise and develop her management skills. The acting manager advised that there was a formal quality monitoring and assurance system in place, which focused on systems audits and monthly management reporting, although reports of the results of these were not provided for inspection. An annual development plan was not provided at the inspection. Service user surveys were not operated, although the manager advised that she planned to organise these and that local authority care management were currently being surveyed. An example of this survey was not provided. She also advised that the home’s equal opportunities police had been recently reviewed. The arrangements for the management and handling of service users monies, focusing on those persons case tracked were examined. These were satisfactory. The manager had introduced a formal system of individual staff supervision, which was being rolled out to all staff, with records kept. The arrangements for ensuring safe working practises in the home were discussed with staff and training records examined. Observations were also made in relation to staff practise during the inspection. These were satisfactory and staff is conversant with their roles and responsibilities and those of their employer with regard to ensuring safe working practises. Satisfactory written details of the maintenance of equipment in the home were provided by way of the pre-inspection questionnaire. Comments made under the Environment section of this report with regard to ensuring a safe environment, including outdoor pathways are also relevant here with regard to the management of the home. The manager was in the process of undertaking a full review of administrative systems in conjunction with the home’s administrator. Systems for the reporting and recording of accidents and untoward occurrences in the home were examined via case tracked and are satisfactory. Staff is conversant with their roles and responsibilities in this area in accordance with the home’s policy and procedural guidance. The Lodge Care Centre DS0000002088.V335615.R01.S.doc Version 5.2 Page 25 The Lodge Care Centre DS0000002088.V335615.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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 2 2 X 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 X X 2 X 3 2 X 2 The Lodge Care Centre DS0000002088.V335615.R01.S.doc Version 5.2 Page 27 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 OP1 Regulation 4&5 Requirement The revised statement of purpose and service user guide must be available for service users. External grounds must be suitable and safe for use by service users and be appropriately maintained. Reference here to the front entrance pathway to the home and the patio/garden area to the rear of the home. The manager of the home must be registered, as it is an offence to manage or carry on a home without being registered. The home’s quality assurance and monitoring systems must provide for formal consultation with service users (and their representatives). Timescale for action 02/06/07 2. OP19 23 02/08/07 3. OP31 CSA Pt2 Sec 11 24 30/06/07 4. OP33 30/06/07 The Lodge Care Centre DS0000002088.V335615.R01.S.doc 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. 1. 2. 3. Refer to Standard OP3 OP7 OP12 Good Practice Recommendations Service users individual needs assessment information should include their preferred daily living routines and lifestyle preferences as agreed with them. Care plans should be drawn up with the involvement of the service user (recorded in a style accessible to them) and agreed and signed by the service user whenever capable. The home should seek to further develop opportunities for service users to exercise choice with regard to their daily living arrangements, leisure and social activities and interests and meals. The home’s complaints procedure should be provided in alternative formats, such as large print, audio etc to make information available to those service users who may have sight difficulties. The grounds/garden should be kept tidy, (safe), attractive and accessible to service users and allow access to sunlight. The results of service user surveys should be published and made available to current and prospective service users, their representatives and other interested parties. There should be an annual development plan in place for the home, based on a systematic cycle of planning action and review and reflecting aims and outcomes for service users. 4. OP16 5. 6. 7. OP19 OP33 OP33 The Lodge Care Centre DS0000002088.V335615.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Care Centre DS0000002088.V335615.R01.S.doc Version 5.2 Page 30 - 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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