Inspection on 21/12/05 for The Lodge Nursing Home

This inspection was carried out on 21st December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 Nursing Home 22/12/06

The Lodge Nursing Home 22/02/05

The Lodge Nursing Home 17/08/04

The Lodge Nursing Home 14/11/03

Similar services:

Bracken House

Sunnycroft

Field Farm House

Edgeview Nursing Home

Church Terrace Nursing & Residential Home

The Forbury

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

CARE HOMES FOR OLDER PEOPLE The Lodge Nursing Home 106 Cannock Road Burntwood Walsall West Midlands WS7 OBG Lead Inspector Mrs Sue Mullin Unannounced Inspection 21st December 2005 10:30 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 Nursing Home DS0000022347.V272883.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. The Lodge Nursing Home DS0000022347.V272883.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Lodge Nursing Home Address 106 Cannock Road Burntwood Walsall West Midlands WS7 OBG 01543 686188 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) Grangemoor Care Homes Karen Morris Care Home 14 Category(ies) of Dementia (14), Dementia - over 65 years of age registration, with number (14), Mental disorder, excluding learning of places disability or dementia (14), Mental Disorder, excluding learning disability or dementia - over 65 years of age (14) The Lodge Nursing Home DS0000022347.V272883.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. DE Dementia minimum age over 60 years MD Mental disorder, excluding learning disability or dementia minimum age 60 years. 10th August 2005 Date of last inspection Brief Description of the Service: The Lodge Care Home is a small homely run nursing home that admits residents with enduring mental health needs, who enjoy high standards of care and individual attention and require nursing care attention 24 hours a day. There are two lounge areas and a separate dining room along with 14 single bedrooms which all have a handbasin. Hairdressing services are available. There is a passenger lift to both floors. The current company Grangemoor Care Homes has run the home since 1993 and it is set in a semi rural location near to Burntwood village, close to the shops and amenities. There are car parking facilities and a pleasant rear garden. The home is very accessible for visitors. The Lodge Nursing Home DS0000022347.V272883.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector undertook this statutory inspection on 21 December 2005 using the National Minimum Standards for Older People as a reference. The care manager was on a day off and the home was in the charge of a first level nurse. There were 13 people in residence with one vacancy. The inspection included the following elements; a sample tour of the building, observation and inspection of records relating to provision of care and discussions with residents and staff. Catering, domestic and laundry aspects were determined and an inspection of the duty rotas confirmed care staffing levels and skill mix. Health & safety issues were also checked. The registered care manager and her team of staff continue to provide high standards of care. A good working relationship was reported with the local GP support and NHS facilities had been accessed when required. The management of health and safety issues had been managed well and no shortfalls were noted. The documentation seen evidenced that the premises were adequately maintained. Since the last inspection in August 2005 there had been no changes to the management of the home, no complaints had been received and no additional visits had been necessitated. What the service does well: It was evident, from discussions with residents, relatives and staff and an inspection of the relevant documentation, that the provision of health and social care had been well met. Residents care plans seen had been completed comprehensively and regularly reviewed. Where possible the care planning process was agreed and supported by residents/representatives. Privacy, dignity and choice aspects for residents were seen being upheld during the caring process. Support was given to people with mental health/dementia care needs, by staff that had knowledge of the residents in regard to their daily living and social activity preferences. Staff engaged in conversation explained ‘ this home is a very friendly place it is like being in your own home’ ‘residents are treated with respect and they get choices of what they like to do’. The staff spoken to did not have any negative comments to make in relation to the services provided in the home. The Lodge Nursing Home DS0000022347.V272883.R01.S.doc Version 5.0 Page 6 There was a robust system in place for the receipt, storage, administration and disposal of medicines. A visitor confirmed that she was actively encouraged to visit her mother and welcomed into the home at all times. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Lodge Nursing Home DS0000022347.V272883.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 The Lodge Nursing Home DS0000022347.V272883.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): 3,4,5 (Standard 6 is not applicable to this home) Residents following a full assessment of their needs had been appropriately admitted to a home that could adequately meet those identified needs. Relatives/residents were encouraged to visit the home prior to making a decision about residency. EVIDENCE: The documentation seen, and a discussion with residents/representatives and staff evidenced that residents had been assessed prior to admission and they had been able to make a choice about the home. All had been given the opportunity to visit the home prior to choosing to stay. A full assessment of each residents needs had taken place before admission and this was seen documented. The community care plans provided by the social worker, as part of the individual needs assessment process, were seen within the documents for those residents funded. Privately funded residents had a comprehensive action plan formulated on admission. The Lodge Nursing Home DS0000022347.V272883.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): 7,8,9,10,11 There was a positive emphasis focused on ensuring the health care needs of the individual were met appropriately and that they were provided with the necessary support to maintain their dignity and independence. The homes routine, practices and staffs attitude promoted privacy. The homes medication system was robust and organised in a safe manner. EVIDENCE: Although many of the residents in the home were unable to comment on their surrounding those who were able to make an opinion commented positively about the care being provided. One relative made a point of expressing their satisfaction to the inspector. The residents care plans and associated documentation seen were complete, reflected the current condition of residents, and had been regularly reviewed. Discussions with both residents and staff members evidenced that health and personal care needs were being well met. The Lodge Nursing Home DS0000022347.V272883.R01.S.doc Version 5.0 Page 10 NHS facilities are accessed when required, and these events were seen recorded. Currently no residents had any wound care requirements. It was observed that a safe system for receipt, storage, administration, and disposal of medicines was in place, and that there was a comprehensive medicines policy document. No resident was ‘self medicating’ and qualified nursing staff delivered all medication aspects. During the inspection it was observed that privacy and dignity were being afforded to residents, and there was very good interaction with staff. Care staff were seen knocking on doors before entering. One resident stated that the staff were very kind. The home had recently experienced a sudden death in the home. Several care assistants were engaged in conversation regarding this incident. It was very pleasing to hear the staff speak compassionately and sincerely about the loss of this resident. The staff were to attend the funeral and pay their respects. They had had foundation bereavement and loss training in house and throughout their induction and NVQ syllabus. The resident died very suddenly and within two hours the care manager went to the relative’s home in person to break the news and discuss the details and offer support. The staff stated ‘ we consoled the relative and offered as much comfort and support as possible’ The Lodge Nursing Home DS0000022347.V272883.R01.S.doc Version 5.0 Page 11 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): 12,13,15 The daily routine within the home was flexible with regards to meeting the needs of the individuals and social contact had been maintained. Residents continue to enjoy leisure pursuits within the home setting. The dietary needs of residents were catered for to reflect the individual’s likes and special dietary requirements. EVIDENCE: A relative explained to the inspector that her mother’s and her family’s views had been listened to, and that they had been able to influence some aspects of the care planning input. Contacts had been maintained, where possible, with relatives and friends and this was seen documented. Christmas entertainment proved a great success in the home and enjoyed by all. One resident spoke of her satisfaction with the meals and choices offered. Dietary requirements of residents were met, including residents’ needs with diabetes, and special diets. The cook when asked said that fresh good quality food from local suppliers was delivered on a regular basis. The care staff knew individual residents preferences. Alternative menus would be provided if requested. The staff stated ‘ the food is very nice, all home cooked, tasty and fresh’. The Lodge Nursing Home DS0000022347.V272883.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): 16,17,18 An open culture existed where complaints or grumbles are listened to and acted upon. Residents are protected from all forms of abuse, and their legal rights are also protected. EVIDENCE: A robust complaints procedure was on display, which contained all the relevant procedures including the commission details. No complaints had been received since the last inspection. No incidents or allegations of abuse of any kind had been recorded. Following a discussion with staff they confirmed that residents are protected from all forms of abuse. Staff stated that all the above issues had been discussed at length during staff induction, training and on-going supervision. Advocate would be facilitated if required by a resident. The Lodge Nursing Home DS0000022347.V272883.R01.S.doc Version 5.0 Page 13 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): 19,21,24,25,26 The home was clean, pleasant and hygienic, and provided a suitable and safe environment for the provision of care. The home has an ongoing redecoration programme. EVIDENCE: A sample tour of the home and a check on the maintenance documentation, evidenced that the home was fit for purpose, clean warm and tidy, and was being well maintained. The laundry, domestic and catering facilities were compliant. The duty rosters evidenced that adequate ancillary staff were employed. Staff when asked had knowledge on infection control, and referred to the relevant documentation. Adequate hand washing facilities were available throughout the home. Bedrooms seen were comfortable, with residents having personal items on show. One resident spoke of her satisfaction with her bedroom. The Lodge Nursing Home DS0000022347.V272883.R01.S.doc Version 5.0 Page 14 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): 27,28,30 Adequate numbers of suitably trained and experienced staff are correctly employed to meet the assessed needs of residents. EVIDENCE: The home provides nursing care and there is a qualified nurse on duty at all times. Additionally on the early shift there are two care staff Late shift there are two care staff Night shift there is one care staff There were 13 residents in the home. There was one vacancy. There is adequate domestic and catering staff in the home The care staff assists the laundry staff to provide seven-day cover Staffing levels are based on the dependency levels of residents in the home and these are reviewed on a regular basis. On the day of the inspection staffing levels and skill mix were found to be acceptable. The home is not currently using any agency cover. The Lodge Nursing Home DS0000022347.V272883.R01.S.doc Version 5.0 Page 15 All mandatory training requirements had had been met and care assistants had benefited from ‘in house’ training, which had covered the needs of the registered client group. The homes recruitment policy, procedures and documentation were examined on the last inspection and all recruitment issues had been handled correctly. This will be rechecked on the next inspection. The Lodge Nursing Home DS0000022347.V272883.R01.S.doc Version 5.0 Page 16 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): 31,32,33,38 A competent and experienced care manager is managing the home, in the best interests of residents and in an open an inclusive atmosphere. The home is being run well, is on a sound financial footing, and has safeguards for the health and well being of residents’ staff and visitors. EVIDENCE: There was a positive ethos of the promotion of normal daily living and the encouragement of the individual resident maintaining their independence. The registered care manager is well experienced, competent and a qualified first level nurse she demonstrates a positive commitment to her role and responsibilities. An open, positive and inclusive atmosphere was observed during the visit and confirmed to the inspector by staff and a relative. Staff The Lodge Nursing Home DS0000022347.V272883.R01.S.doc Version 5.0 Page 17 when asked also said the manager portrayed a clear sense of leadership and direction which enabled them to relate to the aims and objectives of the home. Staff stated ‘ the manager is lovely, approachable we can talk to her and she is very considerate’’ she cares about us and all the residents’. With reference to records and systems relating to the health, safety and the welfare of both the residents and the staff group, records identified the following: • • • • • Nurse call system reported by staff to be fully operational Risk assessments were in place for the individual resident Records that were examined evidenced that fire fighting equipment and systems were checked and serviced on a regular basis Hot water temperature checks were maintained and all in order Emergency lighting/fire alarm tests were up to date and correct There are no outstanding issues known from the Fire Prevention or Environmental Health departments. Accidents were appropriately recorded with a three monthly analysis being undertaken The Lodge Nursing Home DS0000022347.V272883.R01.S.doc Version 5.0 Page 18 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 4 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 4 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 X 3 X X 3 3 3 STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 3 X X X X 3 The Lodge Nursing Home DS0000022347.V272883.R01.S.doc Version 5.0 Page 19 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Lodge Nursing Home DS0000022347.V272883.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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. 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