Inspection on 18/10/07 for White Rose Lodge Retirement Home

This inspection was carried out on 18th October 2007.

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

White Rose Lodge Retirement Home 01/07/10

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Snydale Care Home

Abbey The

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

Carentan House

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

CARE HOMES FOR OLDER PEOPLE White Rose Lodge Retirement Home Limekiln Lane Bridlington East Yorkshire YO15 2LX Lead Inspector Eileen Engelmann Unannounced Inspection 18th October 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 White Rose Lodge Retirement Home DS0000069906.V353392.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. White Rose Lodge Retirement Home DS0000069906.V353392.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service White Rose Lodge Retirement Home Address Limekiln Lane Bridlington East Yorkshire YO15 2LX 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) 01262 400445 Southern Cross OPCO Ltd Care Home 38 Category(ies) of Old age, not falling within any other category registration, with number (38), Physical disability over 65 years of age (4) of places White Rose Lodge Retirement Home DS0000069906.V353392.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - Code PC, to service users of the following gender: Either, whose primary care needs on admission to the Home are within the following categories: Old Age, not falling within any other category - Code OP; Physical Disability over 65 years of age Code PD(E), maximum number of places 4 The maximum number of service users who can be accommodated is 38 New Service 2. Date of last inspection Brief Description of the Service: White Rose Lodge is a care home, which provides a service for people who meet the following criteria of need – Older people (up to 38 places) and older people with a physical disability (four places). The home is situated on the North side of the town of Bridlington, and people living in the home have excellent views of the sea and coastal area. The local shops and amenities are within a short walking distance of the home and there is car parking within the grounds of the home. Accommodation is provided in single and double rooms, the majority of these are single and some have en-suite facilities. Most of the bedrooms have patio doors leading onto the garden areas (ground floor rooms) or a balcony (first floor rooms). People living in the home are provided with a wide variety of communal spaces including lounges, a spacious dining room and an entrance area provided with comfortable settees and chairs. The garden area outside the home is well maintained and people are able to sit and look out over the cliffs towards the sea. An activities organiser is employed by the company to arrange and deliver group and 1-1 activities within the home, as well as booking entertainment sessions from outside sources and organising trips into the local community. Information about the home and its service can be found in the statement of purpose and service user guide, both these documents are available from the manager of the home, and copies are on display in the entrance hall of the home. White Rose Lodge Retirement Home DS0000069906.V353392.R01.S.doc Version 5.2 Page 5 Information given by the manager during this visit indicates the home charges fees from £390.00 to £500.00 per week. The level of fee is dependent on the type of room required and the care input needed. People will pay additional costs for optional extras such as hairdressing, private chiropody treatment, toiletries and newspapers/magazines. Information on the specific charges for these is available from the manager. White Rose Lodge Retirement Home DS0000069906.V353392.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. White Rose Lodge has had a change of ownership in the last year and is now owned by Southern Cross OPCO limited. Since the last visit to the home the service has been re-registered and on this basis is classified by the Commission for Social Care Inspection as a NEW service. Information has been gathered from a number of different sources over the past 6 months since the service was registered with the Commission for Social Care Inspection, this has been analysed and used with information from this visit to reach the outcomes of this report. This unannounced visit was carried out with the manager, staff, visitors and people using the service of White Rose Lodge. The visit took place over 1 day and included a tour of the premises, examination of staff and people’s files, and records relating to the service. Informal chats with a number of people, visitors and staff took place during this visit; their comments have been included in this report. Questionnaires were sent out to a selection of relatives, people living in the home and staff and their written response to these was adequate. We received 4 back from relatives (20 ), 5 from staff (25 ) and 8 from people using the service (40 ). The company completed an Annual Quality Assurance Assessment and returned this to the Commission for Social Care Inspection within the given timescale. What the service does well: People living in the home said they are offered a good choice of meals and they enjoyed the quality of food. Specific wishes are catered for and they have plenty to eat and drink throughout the day. People in the home are provided with a warm, safe and comfortable place to live that welcomes visitors and makes them feel at home. The home is clean and staff work hard to make sure the building is odour free. The home is welcoming and has a relaxed atmosphere. People living there said they are happy with their bedrooms and can bring in their own possessions, making it feel more like home. White Rose Lodge Retirement Home DS0000069906.V353392.R01.S.doc Version 5.2 Page 7 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 summary of this inspection report can be made available in other formats on request. White Rose Lodge Retirement Home DS0000069906.V353392.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 White Rose Lodge Retirement Home DS0000069906.V353392.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, 2, 3, 4 and 6. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People undergo a full needs assessment and are given sufficient information about the home and its facilities prior to admission, to enable them to be confident that their needs can be met by the service. EVIDENCE: The statement of purpose and service user guide is given out to people on admission and copies of the service user guide are found in every bedroom. Each of the packs is available in a large, clear print format and an audio version is also available on request. The majority of people and relatives said they received sufficient information to make an informed choice about the service before accepting the placement offer. These individuals have also received a contract/statement of terms and conditions from the home. Two people said ‘my family looked at a number of homes before deciding this offered the best facilities for me’ and ‘I have returned to the home four times and have always enjoyed my stays here’. White Rose Lodge Retirement Home DS0000069906.V353392.R01.S.doc Version 5.2 Page 10 Four people’s care and records were looked at as part of this visit, they each have been provided with a statement of terms and conditions/contract on admission. Some of these are from the previous owners and the administrator is busy ensuring the contracts/terms and conditions are transferred onto Southern Cross paperwork. Those already done have been signed by the person living in the home or their representative. She is confident that this task will be completed within the next month. The new documents give clear information about fees and extra charges, which will be reviewed and kept up to date. Each person has his or her own individual file and the funding authority or the home, before a placement is offered to the individual, completes a need assessment. The home develops a care plan from the assessments, identifying the individual’s problems, needs and abilities using the information gathered from the person, family and professionals (where applicable) involved in the person’s care. People using the service and relatives are very pleased with the care and support given by the staff, they said ‘the staff are caring and friendly and everyone is well care for’. Survey responses and chats with people using the service show that individuals are confident about the care and satisfied that their individual needs are being met. Information from the Annual Quality Assurance Assessment and discussion with the people living in the home indicates that all of the people are of white/British nationality. The home does accept people with specific cultural or diverse needs and everyone is assessed on an individual basis. Discussion with the manager indicated that the home looks after a number of people from the local community, although placements are open to individuals from all areas. Checks of the staffing rotas and observation of the service showed that the home employs male and female staff. Discussion with the people living in the home indicates that they can express their preferences of staff gender for individuals giving their personal care. The staff training files and the training matrix show that new staff go through an induction before starting work and that the home has a training programme in place. Information from the files and matrix indicates that the majority of staff are up to date with their basic mandatory safe working practice training, and have access to a range of more specialised subjects that link to the needs of people using the service. The employment records show that the manager is using a selective approach to recruitment; ensuring new staff have the right skills and attitude to meet the needs of people in the home. The home does not accept intermediate care placements so standard six is not applicable to the service provided. White Rose Lodge Retirement Home DS0000069906.V353392.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): 7, 8, 9 and 10. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There has been a period of instability in staffing that impacted on the consistency of care within the home, but recent recruitment will make sure there is a good match of well-qualified staff to meet the needs of people using the service. EVIDENCE: The care of four people was looked at in depth during this visit and included checking of their personal care plans. The care plans are in the process of being put onto the new Southern Cross paperwork. It was clear that some staff have done this better than others and discussion with the manager indicated that only senior staff have received training in care planning, but all staff are now writing in the plans. It was recommended that all staff received training around the production and up keep of care plans and the manager should audit these on a weekly basis to make sure they are all up to date. A number of survey responses from staff, relatives and people using the service commented that staffing levels are fluctuating within the home as people are taking time of sick or on annual leave. This is have some impact on White Rose Lodge Retirement Home DS0000069906.V353392.R01.S.doc Version 5.2 Page 12 the quality of care being received by people using the service. One person said ‘I visit most days and the staff are kind and caring. However, they are extremely stressed and tired and things are not getting done because they are overworked and understaffed’. Another person said ‘the staff listen and act on what I say, but they sometimes forget things, probably because of their work load and staff shortages’. Staff commented that they felt frustrated and wanted to provide the care for people when they asked, instead some things were being put off until another day. Ten people using the service were spoken to on the day of the visit, they were aware of minor changes to routines since the home was bought by Southern Cross. These individuals were all optimistic that the ‘hiccups’ in the service were temporary and that issues were being resolved. Discussion with the manager indicated that the company is actively recruiting new members of staff, and these individuals should alleviate a lot of the problems around covering of shifts when they started work. People said that they have good access to their GP’s, chiropody, dentist and optician services, with records of their visits being written into their care plans. They all have access to outpatient appointments at the hospital and records show that they have an escort from the home if wished. Comments from the people and relatives indicate they are satisfied with the level of medical support given to the people living at the home. The staff weighs everyone on a regular basis and evidence in the plans show that dieticians are called out if the home has particular concerns about an individual. Nutritional risk assessments are in place and are updated regularly by the staff. Pressure areas are monitored carefully and proactive measures include risk assessments and special mattresses and seat cushions. A number of people living in the home like to keep fit by walking around the home and into the local town on a daily basis. The medication policy for the home says that individuals can self-medicate if they want to and after a risk assessment has been completed and agreed. All of the people spoken to prefer to have staff administer their medication. Checks of the medication records showed these are up to date and accurate, including those for controlled drugs and refrigerated items. Relatives commented that they are kept informed of their relative’s wellbeing by the staff; they are regularly consulted (where appropriate) on their care and feel involved in their lives. Discussion with ten people using the service showed that overall there is a good level of satisfaction with the care being given to the people living in the home. Chats with people revealed that they are happy with the way in which personal care is given at the home, and they feel that the staff respect their wishes and choices regarding privacy and dignity. Individual comments were ‘the staff treat us with dignity and respect,’ and they encourage us to be as independent as possible’. Observation of the White Rose Lodge Retirement Home DS0000069906.V353392.R01.S.doc Version 5.2 Page 13 service showed there is good interaction between the staff and people; with friendly and supportive help being given to assist individuals in their daily lives. White Rose Lodge Retirement Home DS0000069906.V353392.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): 12, 13, 14 and 15. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are provided with choice and diversity in the meals provided by the home. Individual wishes and needs are catered for and people have the option of when and how they participate in mealtimes. EVIDENCE: Ten people spoken to during this visit told us that activities within the home are ‘low-key’, but that this suited them just fine. The majority of individuals using the home said they try hard to remain independent. Where possible they go out of the home for daily walks, meet with friends and family in the local town of Bridlington, read the local and national newspapers to keep up to date with current affairs, complete crossword puzzles, quizzes and other memory games to keep their brains active, do crotchet and knitting and enjoy a good chat with others in the home. There is an activities organiser who is employed for 14 hours a week and people receive a monthly activities sheet showing what is happening within the home. For the month of October 2007 these activities included Bingo, keep fit, musical entertainment, relaxation sessions, In-door bowls and a Halloween Quiz. Records are kept of all the social interactions going on in the home and evidence seen at this visit indicates that people are encouraged to celebrate White Rose Lodge Retirement Home DS0000069906.V353392.R01.S.doc Version 5.2 Page 15 Christian events such as Birthdays, Easter and Christmas. There are monthly in-house church services from the Church of England, and two people told us that they attend local services at the nearby chapel. Discussion with the people living in the home indicates that they have good contact with their families and friends. Everyone said they were able to see visitors in the lounge or in their own room and they could go out of the home with family or staff would take them into the town. Visitors were seen coming and going during the day, staff were observed making them welcome and there clearly was a good relationship between all parties. Relatives and visitors to the home are very positive about the service and the staff. Written and verbal comments given to us showed a high level of satisfaction. Individuals said ‘my relative has been well cared for since she came here. There has been a definite improvement in her wellbeing’. Another person said ‘the home provides a comfortable and friendly atmosphere in very good surroundings’. Advocacy information is available in a folder in the office on the ground floor and relatives and people using the service are able to read this on request. People spoken to were well aware of their rights and said that they had family members who acted on their behalf and took care of their finances. People said they are satisfied that they can access their personal allowances when needed. Comments from the people living in the home and their relatives are on the whole very positive about the meals and kitchen service provided. Individuals commented that ‘the food is very good’, ‘the chef caters for my specialist diet’ and ‘the meals are perfect’. The lunchtime meal was well presented and offered a good choice of food, menus were available from the kitchen and the dining room was welcoming and spacious. White Rose Lodge Retirement Home DS0000069906.V353392.R01.S.doc Version 5.2 Page 16 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): 16 and 18. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has a good complaints system with some evidence that peoples’ views are listened to and acted upon. Visitors and people using the service are confident about reporting any concerns and the manager acts quickly on any issues raised. EVIDENCE: The home has a complaints policy and procedure that is included in the statement of purpose and service user guide. It is also on display within the home and all twelve of the survey responses from people using the service, and relatives, showed individuals have a clear understanding about how to make their views and opinions heard. Those people spoken to said ‘we would talk to the staff or the manager if we had any problems’. Checks of the complaints records in the home showed that the manager has dealt with two minor complaints in the past six months. Both were investigated and the complainants were happy with the action taken to resolve the issues. The home has policies and procedures to cover adult protection and prevention of abuse, whistle blowing, aggression, physical intervention and restraint and management of people’s money and financial affairs. White Rose Lodge Retirement Home DS0000069906.V353392.R01.S.doc Version 5.2 Page 17 Information in the staff training files showed that 65 of the staff have attended Safeguarding of Adults training, 88 have attended Challenging Behaviour training and 73 have attended dementia awareness. Staff have a good understanding of their roles and responsibilities around Safe Guarding of Adults procedures (abuse) and have knowledge of how and when to make referrals to the appropriate Social Service Teams. Discussion with the people using the service indicates that they feel safe within the home and are confident that staff would help them if they had any concerns or problems. White Rose Lodge Retirement Home DS0000069906.V353392.R01.S.doc Version 5.2 Page 18 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): 19, 21, 22 and 26. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is comfortable and there is a maintenance programme in place to improve the decoration, fixtures and fittings. This will provide people using the service with a better quality environment. EVIDENCE: Observation of the premises showed that the environment is safe, clean and comfortable, but the decoration and furnishings within it are looking a little tired and in need of rejuvenation. Discussion with the manager indicated that the company has recognised the need for refurbishment and that an action plan has been produced to purchase new furnishings and decorate the home on a rolling maintenance programme. There are a number of en-suite rooms, which have a bath or shower within them. These are not being used by the individuals whose rooms these are attached to, as they are difficult for people to get into the baths or step up into the showers. This was discussed with the manager and we were told that the White Rose Lodge Retirement Home DS0000069906.V353392.R01.S.doc Version 5.2 Page 19 company was looking at altering the current en-suite facilities and replacing with more disabled-friendly equipment. This is being dealt with on a request basis. Hoist-assisted bathing is available for all people and there are three bathrooms situated throughout the home. Observation of the second bathroom on the ground floor showed that this is a small room and staff are having difficulties using lifting equipment when bathing people. These concerns were raised with the operations manager during the visit and we were told that consideration would be given to turning the room into a walk-in shower room. The exterior of the home has lawned and garden areas that are well maintained. These are provided with seats and tables and people using these areas are given a wonderful sea view. The home has a large summerhouse in the garden and a number of people spoke of their disappointment this year in not being able to use this facility. Discussion with the manager and operations manager indicated that the patio doors had been broken; new replacements are on order and should be fitted in the near future. Comments from the day of this visit indicate that the people using the service find the home to be spotlessly clean and they are satisfied with the laundry service provided by the home. White Rose Lodge Retirement Home DS0000069906.V353392.R01.S.doc Version 5.2 Page 20 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): 27, 28, 29 and 30. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Recent instability in the staff group has impacted on the home routines, but action is being taken to ensure the needs of the people using the service are met. EVIDENCE: Comments from the relatives and people using the service indicate that the home is extremely busy at times and individuals may wait for attention at peak times, but the friendly attitude of the staff and their willingness to help make up for this. Individuals commented that ‘this is a well run home, but they do not have sufficient care staff on duty’ and ‘the lack of staff causes pressure and stress, which affects the atmosphere in the home’. Comments from staff were that ‘there is always someone on leave or calling in sick, which leaves the rest of us covering additional shifts’ and ‘I love my job, but it would be nice to have enough staff to make everyone happy’. The manager and operations manager told us that they have been recruiting for new employees and are waiting for police checks to clear before individuals can start work. Agency staff are being used in the interim period. There have been some staff changes since Southern Cross took over the business, and a number of small changes to the work and daily routines within the home. These have all caused unrest amongst those working in the home and living there. However, conversation with ten individuals showed that they remain White Rose Lodge Retirement Home DS0000069906.V353392.R01.S.doc Version 5.2 Page 21 positive about the service and confident that the company are working towards resolving any problems. At the time of this visit there were 33 people living in the home and the staffing rotas show that there are Early shift – four care staff on duty Late shift – three care staff on duty Night shift – two care staff on duty Information from the Annual Quality Assurance Assessment about the number of staffing hours provided, and information gathered during the inspection about the dependency levels of the people using the home, was used with the Residential Staffing Forum Guidance. The homes information said that 504 care hours are being provided and the Guidance indicates that 592 should be in place. These figures do not include the manager’s hours or those for domestic and cleaning activities. Recent recruitment of additional staff may make up the difference in hours, but the responsible individual must make sure that sufficient staff are on duty at all times of day and night to meet the needs of the people using the service. There is an induction course for new members of staff, and 60 of the care staff have achieved an NVQ 2 or 3. The home provides a mandatory staff-training programme and this includes some more specialised training to help staff develop their skills and knowledge around pressure care, care planning, customer care, dementia, challenging behaviour management and safeguarding of adults. The manager said that training in Equality and Diversity has not taken place although it is discussed informally at staff meetings and supervision. It is recommended that the responsible individual should try to source some equality and diversity training for staff members. The home has an equal opportunities policy and procedure. Information from the staff personnel and training records and discussion with the manager, shows that that this is promoted when employing new staff and throughout the working practices of the home. The home has a recruitment policy and procedure that the manager understands and uses when taking on new members of staff. Checks of four staff files showed that police (CRB) checks, written references, health checks and past work history are all obtained and satisfactory before the person starts work. White Rose Lodge Retirement Home DS0000069906.V353392.R01.S.doc Version 5.2 Page 22 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): People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management of the home is satisfactory overall and the home reviews aspects of its performance through a programme of audits and consultations, which includes seeking the views of people using the service, staff and relatives. EVIDENCE: The manager is registered with the Commission for Social Care Inspection and has just completed her Registered Manager’s Award. She attends regular training updates to keep her skills and knowledge current and proactive. The manager has a good understanding of the areas in which the home needs to improve and arrangements are being progressed for them to be sourced and implemented. The home is working towards achieving the local council’s Quality Assurance Award (QDS 1 and 2). The manager is completing monthly audits of the White Rose Lodge Retirement Home DS0000069906.V353392.R01.S.doc Version 5.2 Page 23 service and the responsible individual has completed the monthly regulation 26 reports, and a copy of these is available for inspection within the home. Meetings for the staff and people using the service are taking place; minutes are kept and are available for any interested parties to read. Policies and procedures are up dated and reviewed as an ongoing practice. Feedback is sought from the people living in the home and relatives through regular satisfaction questionnaires, and the manager is in the process of producing an annual development plan to highlight where the service is going and/or indicate how the management team is addressing any shortfalls in the service. Checks of the finance systems within the home found that computerised records are kept for people’s personal allowances; the administrator on a daily/weekly basis up dates these. People who have asked the home to look after their personal allowances are able to access their money on request, and receipts are kept for any transactions. All monies are kept safe and secure within the home and only the administrator or manager has access to the funds. Maintenance certificates are in place and up to date for all the utilities and equipment within the building. Accident books are filled in appropriately and regulation 37 reports completed and sent on to the Commission where appropriate. Staff have received training in safe working practices and the manager has completed generic risk assessments for a safe environment within the home. Risk assessments were seen regarding fire, moving and handling, cot sides and daily activities of living. White Rose Lodge Retirement Home DS0000069906.V353392.R01.S.doc Version 5.2 Page 24 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 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 2 X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 White Rose Lodge Retirement Home DS0000069906.V353392.R01.S.doc Version 5.2 Page 25 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 OP22 Regulation 23(2)(n) Requirement Timescale for action 01/06/08 2. OP27 18(1)(a) The responsible individual must make sure that an assessment of the bathing facilities in the home (en-suites and communal bathrooms) is undertaken. Where necessary, environmental adaptations must be made ensure the facilities meet the needs of the people using the service. This will provide people with bathing facilities that encourage and support their independence and meet their specific disability needs. The responsible individual must 01/02/08 ensure there are sufficient staffing numbers and skill mix of staff to meet the assessed needs of the people, the size, layout and purpose of the home at all times, and additional staff are on duty at peak times of activity during the day. So people can enjoy a good quality of life and be confident that their health and social care needs will be met. White Rose Lodge Retirement Home DS0000069906.V353392.R01.S.doc Version 5.2 Page 26 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. 4. 5. Refer to Standard OP7 OP7 OP21 OP21 OP30 Good Practice Recommendations The manager should make sure that all staff receive training around the recording and up keep of care plans. The manager should audit the care plans on a weekly basis to make sure they are all up to date. The registered provider should consider turning the small bathroom on the ground floor into a walk-in shower room. Where en-suite bathing facilities are not suitable for use by disabled individuals, consideration should be given to replacing them with a more suitable facility. The responsible individual should try to source some equality and diversity training for staff members. White Rose Lodge Retirement Home DS0000069906.V353392.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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. 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