Inspection on 05/05/06 for The Lodge Care Centre

This inspection was carried out on 5th May 2006.

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 Care Centre 02/05/07

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 Lodge, The Care Centre Bridge Street Killamarsh Sheffield Derbyshire S21 1AL Lead Inspector Gail Meads Key Unannounced Inspection 5th May 2006 10:00 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.V293906.R01.S.doc Version 5.1 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.V293906.R01.S.doc Version 5.1 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 Vacant 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.V293906.R01.S.doc Version 5.1 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 1st December 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.V293906.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit that took place at the home over a 6 hour period time was also spent in preparation for the visit, looking at previous reports and other documents. During the inspection apart from examining a number of the homes records, resident and staff files, time was spent looking around the building and speaking to residents and relatives the manager and staff. Various records including residents individual care plans, staff files and records were examined the findings are recorded in the body of this report. What the service does well: What has improved since the last inspection? The administrative systems and structures continue to improve. Lodge, The Care Centre DS0000002088.V293906.R01.S.doc Version 5.1 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.V293906.R01.S.doc Version 5.1 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.V293906.R01.S.doc Version 5.1 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): 1.2.3.4.5.6. The home has a Statement of Purpose and Service User Information Guide in Place. Full needs assessments are carried out to ensure that the home has sufficient information to be able to judge if the home provides the services needed. Relevant Information is given to potential residents to enable them to make an informed choice about the homes services. Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to the service. EVIDENCE: The home has a Statement of Purpose and Service user Information Guide in place these documents were examined and found to be satisfactory. Three residents files were assessed for the purpose of case tracking all three has full needs assessments carried out, although one had not been completed until the day of admission, the manager stated that this practice would change has he intended to visit and assess all potential residents prior to admission. Trial periods are offered and some residents have experienced day care prior to being offered a place of residency at the home. All three residents had a Terms Lodge, The Care Centre DS0000002088.V293906.R01.S.doc Version 5.1 Page 9 and Condition/contract in place which were assessed and found to be satisfactory. Standard 6 is not provided at this home. Lodge, The Care Centre DS0000002088.V293906.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7.8.9.10. A wide range of health services are provided for residents. The administration and recording of medication was not in keeping with the medication policy. Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to the service. EVIDENCE: All three of the residents assessed during this inspection had individual Care Plans in place, which were detailed and informative. Risk assessments had been completed and reviews were now taking place as required. The three residents files examined had evidence that a wide range of health services were given to residents there is a record of all health visits made which showed that the residents had received visits from a general practitioner, district nurse, dental care, eye and hearing tests and chiropody were all provided as and when needed. There was evidence in the files to indicate that residents were offered the choice of self-medicating if they were capable and safe to do; disclaimers were signed to give the home the responsibility of administering medication. The Medical Administration Records were examined and it was found that there had been several occasions where medication had been administered but not Lodge, The Care Centre DS0000002088.V293906.R01.S.doc Version 5.1 Page 11 recorded as required. Several residents and relatives were spoken to during this inspection and they stated that they were respected by the staff and could not fault the service they received from staff. Staff were observed during the inspection knocking at residents doors shutting toilet doors to enable residents to have some privacy, locks have been fitted to residents door and keys are given to residents where appropriate and safe to do so. Staff were observed talking to residents in a caring manner and the residents were enabled to move at their pace and not rushed. It was noted during the inspection that a number of residents were being moved by staff in their wheelchairs without the foot rests being used. Lodge, The Care Centre DS0000002088.V293906.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12.13.14.15. Residents are offered a range of activities, routines are minimised where possible. Relatives and visitors are encouraged to visit and made welcome. Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to the service. EVIDENCE: The home has an ‘open door’ policy in place for visitors, it was noted that there were a number of visitors to the home during this inspection and the visitors book identified a number of regular visitors to the home. A small number of visitors were spoken to during this inspection all confirmed that they could visit at almost any reasonable time and that they were offered tea and made to feel welcome by staff. The home has a designated Activities co-ordinator who is employed for 22 hours per week a programme of activities is in place and a range of leisure and social activities are provided. A records of residents participation in leisure and social activities in maintained on residents personal files.There are regular visits made to the home by the local vicar and the priest visits as and when needed. The home can access a company mini bus if residents want to go out on trips. The acting manager stated that residents are encouraged to make choice about the day to day running of the home resident meetings are held on a regular three monthly basis residents relative are invited to join these meeting and the record of these meetings indicated that a small number of relatives Lodge, The Care Centre DS0000002088.V293906.R01.S.doc Version 5.1 Page 13 had join the meetings. Staff spoken to confirmed that residents meetings were held but had difficulty in recalling when the last one took place. A resident spoken to during the inspection felt it would be nice to have more than one bath a week, an assurance was given by the manager that this would be rectified with the resident and residents would be told that more than one bath could be made available as and when requested. The homes menus were examined and found to be satisfactory. The lunchtime meal was observed staff were supportive of residents who needed assistance Staff referred to residents address by their names. Staff spoke to residents sensitively and calmly. The food provided was well presented and looked appetising. The dining area is light, warm and clean. tablecloths are provided and flowers were on each table. Special diets are catered for including diabetics and liquid meals. The likes and dislikes of residents are identified on the assessments carried out and passed to the kitchen staff. The stocks of food were good and there was evidence of fresh fruit and vegetables. Lodge, The Care Centre DS0000002088.V293906.R01.S.doc Version 5.1 Page 14 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): 16.17.18. The home maintains a complaints record and complaints are dealt with according to the homes own complaints policy. Staff have attended Protection of Vulnerable Adults training and the home has a robust recruitment policy in place. Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to the service. EVIDENCE: There had been two complaints since the last inspection dated 01/12/05 both had been dealt with promptly one had been resolved and the second was ongoing. The manager stated that complaints are taken seriously and responded to promptly. Staff have now attended Protection of Vulnerable Adults training and staff spoken to on the day of the inspection confirmed this. The home has a robust recruitment policy and procedure in place, two staff files were examined and found to contain evidence that both the Protection of Vulnerable Adults and Criminal Record Bureau had taken place and two references had been taken up prior to being employed. Residents are able to have advocates if requested and the residents spoken to during this inspection were quite clear about how to complain if they needed to although most stated that they would speak to there family or the manager in the first instance. Lodge, The Care Centre DS0000002088.V293906.R01.S.doc Version 5.1 Page 15 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): 19.20.21.22.23.24.25.26. The environment meets the required standards. Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to the service. EVIDENCE: A tour of the building was carried out and the building was found to be ‘fit for purpose’ There are sufficient toilets, bath and shower rooms provided to meet the needs of the residents. The home provides a range of lifting equipment including a shaft lift. Toilet and bath aids are provided to assist residents to toilet and bathe safely. Grab rails are fitted and wheel chair access is provided throughout the building. The lounge and dining area are furnished appropriately, there is a garden provided where residents can sit if they wish to do so and weather permitting there is wheelchair access to the garden. A number of residents’ bedrooms were assessed and they were found to contain the furniture and fittings as identified in Standard 24 of the National Minimum Standards. All the bedrooms assessed were personalised and had items of the residents own furniture in evidence. Lodge, The Care Centre DS0000002088.V293906.R01.S.doc Version 5.1 Page 16 There is good ventilation provided throughout the home water supply is thermostatically controlled and safe surface radiators are fitted throughout the home. The home was found to be clean and warm there were no offensive odours noted and the building is well maintained internally and externally. Lodge, The Care Centre DS0000002088.V293906.R01.S.doc Version 5.1 Page 17 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): 27.28.29.30. Staffing levels have increased to meet the identified needs of residents. All staff have received the mandatory training but would still benefit from a wider range of training. The home has a robust recruitment policy in place. Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to the service. EVIDENCE: The staff rotas were examined and copies retained which indicated that one manager and five care workers are available during the morning shift and five on in the afternoon, one care worker is on shift 4- 10pm. One Registered General Nurse and two carers are provided for the night shift. There are also two housekeepers, one cook and one kitchen assistant, one maintenance worker, and one administratator. A training matrix for staff is now displayed on the notice board in the front entrance which provides evidence that staff have received their mandatory training staff spoken to confirmed that they had received the training and also received Induction training and supervision. Two staff files were examined including a new member of staff all the documents identified in Schedule 2 was available for inspection and were found to be satisfactory. Over 50 of care staff have now achieved their National Vocational Qualification Training level 2 but no staff had achieved any higher level, staff spoken to on the day of the inspection indicated that they had asked to do level three but this had not been made available. The manager stated that Lodge, The Care Centre DS0000002088.V293906.R01.S.doc Version 5.1 Page 18 more training was now being planned so staff should benefit from a range of training not just the mandatory in the future. Staff spoken to stated that they were still times during the day when staff felt under pressure and that staffing levels were not always enough to cope with residents needs as efficiently a staff would like. One of the complaints made by a relative also made reference to staff shortages. Staff spoken to also spoke of staff morale being ”at an all time low” this was pursued and staff felt that the manager was not really interested in them, and they stated as a result they did not have confidence in the manager. Lodge, The Care Centre DS0000002088.V293906.R01.S.doc Version 5.1 Page 19 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): 31.32.33.35.37.38. An acting manager is in post and has started the process of registration process to become the registered manager. A Quality Assurance system as yet to be fully developed. Health and safety issues are addressed and recorded as required. Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to the service. EVIDENCE: Staff spoken to during the inspection felt that the manager was not listening to them and as a result they had no confidence in him. Residents and relatives spoken to stated that they found him to be “pleasant” and “seems a nice enough chap” this was discussed with the manager who stated he was surprised by these comments and gave assurances that this situation would be addressed. The systems and structures in place at the home have improved and benefited from the managers input, as had the staff training. Lodge, The Care Centre DS0000002088.V293906.R01.S.doc Version 5.1 Page 20 It was apparent throughout the inspection that the manager was familiarising himself with the home and had started to make administrative changes in the needs assessments, Care plans and maintaining records generally. Quality Assurance systems and structures for the monitoring reviewing and evaluating the services offered were being developed but the information gathered had not been made into a published document. Resident and relatives meetings were held and recorded as were staff meetings Staff supervision was now planned for all staff and a supervision plan was examined, evidence was seen during the inspection of supervision taking place and the staff spoken to during this inspection confirmed they were receiving supervision. Records are maintained of all residents’ financial transaction these records were examined and a number of residents monies held by the home were examined and found to be satisfactory. The homes accounts could be made available if the need should arise. Regulation 26’s were now being completed as required by the regional manager. A number of records were assessed during this inspection including staff rotas, menus, Care plans, staff files, accidents and complaints, all were found to be satisfactory The home has Health and Safety posters displayed in the home, protective clothing is provided for staff throughout the building. Control of Substances Hazardous to Health is adhered to and all such substances are kept locked away from residents. The service records of the home including Gas, electrics, lifting equipment, and fire alarm test and training all were found to be current and satisfactory the home has a current insurance and registration document displayed. Lodge, The Care Centre DS0000002088.V293906.R01.S.doc Version 5.1 Page 21 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 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 3 3 3 3 3 Lodge, The Care Centre DS0000002088.V293906.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP31 Regulation 8,9 Requirement The registered person must appoint a registered manager. This person must undertake the ‘fit person’ process. The recording of medication must take place at the time of administration. Timescale for action 01/06/06 2. OP9 13(2) 01/06/06 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. Refer to Standard OP8 Good Practice Recommendations The registered provider must discuss the staffs lack of confidence in the acting manager to ascertain what action may need to be taken to improve the management/ staff relationship. A Quality Assurance system for the monitoring reviewing and evaluating the services offered must be further developed to include a published document of the findings. The registered person must ensure that staff receive adequate training. 2. 3. OP33 OP18 Lodge, The Care Centre DS0000002088.V293906.R01.S.doc Version 5.1 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.V293906.R01.S.doc Version 5.1 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!