Inspection on 22/09/05 for Warren Lodge Care Centre

This inspection was carried out on 22nd September 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Warren Lodge Care Centre 28/11/08

Warren Lodge Care Centre 15/11/06

Warren Lodge Care Centre 05/01/06

Warren Lodge Care Centre 01/02/05

Warren Lodge Care Centre 22/07/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Warren Lodge Warren Lane Finchampstead Wokingham Berkshire RG40 4HR Lead Inspector Stewart Mynott Unannounced Inspection 22nd September 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 Warren Lodge DS0000011404.V249698.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. Warren Lodge DS0000011404.V249698.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Warren Lodge Address Warren Lane Finchampstead Wokingham Berkshire RG40 4HR 0118 973 4576 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) Phoenix Healthcare Limited Care Home 41 Category(ies) of Dementia - over 65 years of age (11), Old age, registration, with number not falling within any other category (30) of places Warren Lodge DS0000011404.V249698.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st February 2005 Brief Description of the Service: Warren Lodge is a large adapted house with a ground floor wing added. A communal lounge and separate sun lounge is provided along with dining room and two assisted bathrooms on the ground floor. The majority of the rooms are en-suite with showers and/or baths. A shaft lift is available to the second floor, which has another two bathrooms. The home is well decorated with attention to detail with its furnishings. The rooms are all individualised with their carpets and curtains. The rooms vary in size and design, one of which has the benefit of a small conservatory. The home is situated in secluded area with views over the countryside at the rear. There is large well-maintained garden with a small aviary. The home is registered to provide care for eleven individuals with a primary diagnosis of dementia who do not require nursing care. This unit is called “The Courtyard”, the unit provides different activities and also benefits from garden which is safe and secure and was designed specifically for the needs of the service users, it has a large ramp to enable access for less mobile service users to the garden. Warren Lodge DS0000011404.V249698.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection during the day lasting for 7 hours. The manager/proprietor conducted a full tour of the home. Time was spent in discussion with residents during which observation of daily life were made, particularly in the Courtyard unit. Time was also spent talking to the deputy care manager, care staff, and the manager/proprietor. Some of the homes records including care records were examined to further evidence observations made during the inspection. A discussion with service users and staff revealed that the term of resident was preferred to service user and hence this term id used throughout his report. What the service does well: What has improved since the last inspection? There had been maintenance work carried out to ensure water temperature was within safe levels for residents. There also has been a significant improvement to the recording and monitoring of complaints within the home. Further developments to the medication system have occurred following a visit from a pharmacist inspector earlier in the year. Warren Lodge DS0000011404.V249698.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Warren Lodge DS0000011404.V249698.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 Warren Lodge DS0000011404.V249698.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): Standards 1 to 6 were not assessed during this inspection. EVIDENCE: Warren Lodge DS0000011404.V249698.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 and 10 Resident’s personal, health and social care needs are being met. Residents confirm they are treated with the utmost dignity and respect. EVIDENCE: All residents have a care file that details a variety of documents including care plans and daily contact sheets. With the exception of the Courtyard, residents have the personal care part of their plan in their bedroom. Four residents spoken to were aware of their care plans and agreed with their content. The four care plans for these residents were examined and were detailed with clear information in regards to personal care needs and support required by staff to achieve these needs. Care plans also included support required for each part of the day, which was clear and easy to understand. Two further care plans for residents within the Courtyard further detailed information in regards to care needs associated with dementia. Senior staff members regularly review care plans. Six residents health care needs were tracked during the inspection. Care records revealed monitoring of nutrition, risk assessments and other health needs. In all cases these records were complete and regularly reviewed. The Warren Lodge DS0000011404.V249698.R01.S.doc Version 5.0 Page 10 deputy care manager explained the process for attending to health needs of residents including access to GP and district nurses. Clear records of these visits are kept in individual care records as well as a separate central record. Four residents discussed their current health needs and confirmed full access to all local NHS facilities. One resident confirmed they have regular visits from an occupational therapist to assist with mobility issues. The medication system was explained fully be the deputy care manager. A pharmacist inspector had visited earlier in the year and requirements and recommendations relating to this visit were followed up and fully met. The current system of ordering, administration and returning medicines is clear and supported by the local pharmacy. Medication charts are generated on the homes computer and those viewed were complete with a system to identify initials of staff member administering medication. The system for administering controlled medicines was examined and records were clear and tallied with medicine in stock. All staff administering medication had received training as evidenced in staff training records. All residents spoken to confirmed that they were treated with respect and dignity by the staff team. Residents described the staff as “very kind and caring” and confirmed all personal care is given in private. Staffs were observed to be highly professional and unobtrusive at all times ensuring residents needs were met. Three residents confirmed that all post arrives unopened and they use a personal telephone line in their bedroom. One resident described access to a telephone in a quiet lobby area where calls were transferred to for private conversations. Warren Lodge DS0000011404.V249698.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): 14 Residents are enabled to exercise full choice and control over their lives. EVIDENCE: The manager/proprietor and several staff described the ethos of the care home to enable residents to exercise full choice and control over their lives wherever possible. All residents spoken during the day confirmed that they were able to choose how they received their care and staff respected their preferences and personal routines. One resident described how her choice of alcoholic beverage and its timing was always observed by the staff. Another resident stated that staff “assist when I need them to”. Two residents discussed their ability to manage their own financial affairs without any intrusion. Observations during the day confirmed the views expressed by residents. Warren Lodge DS0000011404.V249698.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 and 18 There is a positive use of the complaints procedure that is clearly understood by residents that feel their views are taken seriously. Clear procedures are in place to protect residents from harm. EVIDENCE: There is a complaints and concerns procedure displayed on the wall and also in the resident’s handbook (statement of purpose). Four residents confirmed that they were fully aware of the procedure to raise concerns or complaints and would be comfortable to do so. One resident had complained since the last inspection and was happy that the matter was resolved quickly and her views had been taken seriously. This complaint was recorded in the complaints book. Five staffs were spoken to and were clear on how they would deal with complaints made by residents and how these would be reported. The complaints book was examined and revealed twelve complaints since the last inspection. All complaints were non-serioius and were resolved quickly. The reporting of these complaints demonstrated an open culture with a positive view on improving quality of service. This practise is viewed as commendable. There is a policy for preventing abuse in place. The manager/proprietor delivers in house training for staff on preventing abuse. Training records revealed that nearly all staff had received this training within the past year. The content of the course was viewed and felt to be sufficiently detailed. Five staffs spoken to were able to convey their understanding in this area. Warren Lodge DS0000011404.V249698.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, 20, 21, 24, 25 and 26 Residents live in a very comfortable, homely and clean home maintained to a very high standard. EVIDENCE: A full tour was given by the manager/proprietor, which included all areas within the home. The premises are maintained and decorated to a very high standard throughout. The communal areas including the lounge and dining room are comfortable and homely and residents were seen to be enjoying these areas. Residents spoken to described these areas as “homely” and “well kept”. The Courtyard is purpose built and provides good accommodation for service users with a dementia including a separate garden with an aviary created to a high specification. The main garden is extensive and well maintained with fine views, which many residents commented they enjoyed. A patio area was in use by residents during the inspection. Warren Lodge DS0000011404.V249698.R01.S.doc Version 5.0 Page 14 Several residents bedrooms were viewed all of which were individually decorated, very clean with en-suite facilities. Residents spoken to were highly satisfied with their rooms and confirmed that they were encouraged to bring their personal items with them when they moved in. Most bedrooms are en-suite, however communal bathrooms with specialist equipment is provided as required by many residents. Bathrooms were observed as clean and comfortable. The laundry assistant discussed how the system for laundering of clothing and other items operated, which appeared effective and organised. The laundry was clean and non-cluttered with adequate washing machines and a dryer. The laundry assistant was clear on the prevention of cross infection and the policy was on display in the laundry and adjacent sluice room. The house keeping system in the home is effective and discreet as evidenced by the high standard of cleanliness and lack of offensive odours in all areas inspected. Residents spoken to also confirm that the home is always clean and tidy and that they were happy with this area of service. The local fire safety officer had inspected the home recently. The fire officer identified a number of areas that required attention. These have been actioned promptly within the timescale specified. One requirement outstanding is in relation to doors, which for practical reasons can only be completed on a rolling program. The manager/proprietor is arranging an extension to complete this work and is required to notify the CSCI when the new timescale has been arranged. It is only for this reason that the premises has been scored as not met, as in all other areas relating to this standard should be considered as being exceeded. Warren Lodge DS0000011404.V249698.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 and 30 There is a good staffing level at the home to ensure resident’s needs are met. Staffs receive induction training and a varied training program and are knowledgeable and competent. The homes recruitment process for non-care staff was not satisfactory with all relevant checks not being in place prior to employment. EVIDENCE: There was seven care staff including the deputy care manager on duty during the morning with five care staff during the afternoon. Two of these staffs are deployed to work in the Courtyard unit. Staff rotas for the previous four weeks were examined and staffing levels were seen to be constant without the requirement to use agency staff. From observations the staffing level appeared sufficient and the higher staffing level during the morning reflected some of the activities occurring in peak times to meet residents needs. One residents spoken to confirmed, “staff are always on hand when needed”. Other residents also shared this view. The recruitment records of the last two staff that were employed were examined. Both these staffs were not employed in a care capacity. The personnel files indicated that a detailed application form was completed and interviews took place prior to appointment. It was noted that a CRB or POVA First check had not been taken prior to appointment. In addition one of the staff members had commenced employment before both references had been received. This is regarded as a serious shortfall. A personnel file of a longWarren Lodge DS0000011404.V249698.R01.S.doc Version 5.0 Page 16 standing member of the care team was examined and found to be fully compliant with regulation and schedule. Staff training records for all staff were examined and a good range of training had been organised over the previous two years. Nearly all staff had dementia and prevention of abuse training; statutory training was also seen to be in date. Staff confirmed their attendance and felt the training at the home was good. Two recent induction records were viewed and seen to be complete with the direction of the manager/proprietor and senior team. Warren Lodge DS0000011404.V249698.R01.S.doc Version 5.0 Page 17 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 and 32 Residents live in a home that is effectively managed by a competent and trained manager/proprietor. The manager/proprietors approach ensures an excellent quality of service is provided for residents. EVIDENCE: The manager/proprietor is qualified to include the Registered Manager Award and training records reflect that update training is regularly undertaken. The manager/proprietor clearly drives the excellent ethos of the care home. This was evident in the excellent quality of service observed and confirmed by residents throughout the inspection. Staffs spoken to are very clear about their expectations, which further demonstrate the clear sense of direction and leadership, provided by the manager/proprietor. The relationship between senior staff members was confirmed as professional and supportive. Warren Lodge DS0000011404.V249698.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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 4 15 X COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 3 2 4 3 X X 4 3 3 STAFFING Standard No Score 27 3 28 X 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 X X X X X X Warren Lodge DS0000011404.V249698.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP19 Regulation 23(4) Requirement Timescale for action 31/10/05 2 OP29 19 and schedule 2 The Registered Person ensures that a new timescale to complete the outstanding work detailed in the fire safety officer’s report is arranged and that this work is completed within this new timescale. The CSCI is to be advised of this timescale. The Registered Person must 23/09/05 ensure that all staffs have appropriate POVA and CRB checks in place and both references are received prior to employment. Repeated requirement. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Warren Lodge DS0000011404.V249698.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Berkshire Office 2nd Floor 1015 Arlington Business Park Theale, Berks RG7 4SA 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 Warren Lodge DS0000011404.V249698.R01.S.doc Version 5.0 Page 21 - 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. 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