Inspection on 06/06/05 for Yercombe Lodge

This inspection was carried out on 6th June 2005.

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

Yercombe Lodge 01/10/08

Yercombe Lodge 04/10/06

Yercombe Lodge 08/03/06

Yercombe Lodge 12/01/05

Yercombe Lodge 29/07/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE Yercombe Lodge Stinchcombe Dursley Glos GL11 6AS Lead Inspector Sharon Hayward-Wright Unannounced 6th June 2005 11:00 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 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. Yercombe Lodge D51_D03_S16660_YercombeLodge_V227888_060605_Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Yercombe Lodge Address Stinchcombe Dursley Glos GL11 6AS 01453 542513 01453 519216 yercombe@btopenworld.com Yercombe Trust Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs. Angela Kathleen Turner Care Home - Care Home only 11 Category(ies) of PD(E) Physical dis - over 65 (11) registration, with number PD Physical disability (11) of places OP Old age (11) Yercombe Lodge D51_D03_S16660_YercombeLodge_V227888_060605_Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 12 January 2005 Yercombe Lodge D51_D03_S16660_YercombeLodge_V227888_060605_Stage 4.doc Version 1.30 Page 5 Brief Description of the Service: Yercombe Lodge is an Edwardian property that has been sympathetically adapted and extended to provide accommodation for long-term and respite care for older people over 65 years and for anyone over the age of 18 with a physical disability. The home does not provide nursing care. All bedrooms are pleasantly decorated and comfortably furnished; four have en-suite facilities. The home is equipped with three assisted bathrooms and one of these includes a shower. The home provides additional aids to assist service users and a shaft lift provides access to the first floor. Comfortable and spacious communal areas are located on the ground floor, all of which have the benefit of extensive and attractive views over the surrounding countryside. A small kitchen has been provided on the first floor for service users to prepare their own breakfast if they choose. The home has large landscaped gardens that may be enjoyed by the service users in good weather. Yercombe Lodge D51_D03_S16660_YercombeLodge_V227888_060605_Stage 4.doc Version 1.30 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 3 hours one day in June. Four service users were spoken with to gain their views on the home and the care provided. Three service users’ care was examined in detail. Two staff members, the Deputy Manager and Registered Manager were also spoken with. Staff were observed going about their duties and interacting with each other and service users. A part tour of the premises took place and lunchtime was observed. Care and food records, duty rotas, quality assurance and maintenance records were examined. Two requirements issued at the last inspection have been addressed. What the service does well: What has improved since the last inspection? Risk assessments have been included in service users’ care plans to ensure the safety of service users’. Infection control procedures are in place to reduce the risk of cross infection. Yercombe Lodge D51_D03_S16660_YercombeLodge_V227888_060605_Stage 4.doc Version 1.30 Page 7 Quality assurance systems are now in place, but further improvement is needed. 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. Yercombe Lodge D51_D03_S16660_YercombeLodge_V227888_060605_Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Yercombe Lodge D51_D03_S16660_YercombeLodge_V227888_060605_Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2, 3 & 5 Arrangements are in place to ensure service users’ are not admitted to the home without first having their needs assessed and the opportunity for them to visit the home. EVIDENCE: The care files of three service users were examined and all of these were receiving respite care. One of these service users’ was at the home for the first time. All three had completed an application form detailing any areas they need assistance with. Each service user where able, visits the home prior to moving in for respite care and all three service users’ confirmed this. Assessments of their care needs have been completed by the home and were seen in their care files. The new service user said she was told about the service by her local GP’s surgery and that the home has a very good reputation in the local community. Copies of the homes terms and conditions, signed by the service users, were seen in the care files examined. Yercombe Lodge D51_D03_S16660_YercombeLodge_V227888_060605_Stage 4.doc Version 1.30 Page 10 Yercombe Lodge D51_D03_S16660_YercombeLodge_V227888_060605_Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 & 10 The home has a clear and consistent care planning system in place to adequately provide service users’ with a plan of care to meet their needs. However care plans must be individualised for specific service users needs. Service users’ have the opportunity to access outside health professionals for their assessed needs. Personal support in the home is offered in such away as to promote and protect service users’ privacy and dignity. EVIDENCE: Three service users’ care was examined in detail and one further care plan was examined. All service users were receiving respite care. The home had not reviewed all of these care plans as this was due to happen on the day of the inspection. However one service user’s care plan had been updated due to a change in their medical condition. The new service user did not have any care plans devised for the reason mentioned above. This was due to be address immediately following the inspection. Yercombe Lodge D51_D03_S16660_YercombeLodge_V227888_060605_Stage 4.doc Version 1.30 Page 12 Written plans of care were in place for all service users’ except the new service user, however more information is needed on certain care plans to ensure the care is individualised. For example the care plans for personal care state “assistance of one carer is needed”, but it does not state what assistance is needed. All care plans inspected had evidence of reviews. Risk assessments are in place for service users who have an assessed need. Health services are accessed for service users with an assessed need. The local GP was visiting the home during the inspection. Staff were observed undertaking their duties and interacting with service users. The staff were seen to maintain service users’ privacy and dignity at all times. Service users also confirmed this is the case. Yercombe Lodge D51_D03_S16660_YercombeLodge_V227888_060605_Stage 4.doc Version 1.30 Page 13 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 standard(s) 14 & 15 Dietary needs of service users’ are well catered for with a balanced and varied selection of food available that meets service users’ tastes and choices. Service users’ are able to make choices over how they spend their time each day. EVIDENCE: Service users’ spoken with said they are able to chose how they spend their time each day. The homes application form asks for example, what time they get up and go to bed and service users’ confirmed they are able to maintain their normal routine. Service users’ said that they could choose to spend the day in the communal areas or in their own rooms. After lunch a number of service users’ returned to their rooms. A small number of service users’ personal belongings were seen in the respite rooms. The kitchen staff provided evidence that the appropriate health and safety checks are undertaken. The records maintained for food provided were up to date except that alternatives were not always documented. Lunchtime was observed and found to be a very social event with all service users’ at the time of the inspection taking their meals in the communal dining Yercombe Lodge D51_D03_S16660_YercombeLodge_V227888_060605_Stage 4.doc Version 1.30 Page 14 room. Choices were offered and service users were able to take as long as they wished to finish their meals. The staff also have their meals with the service users. Service users’ all said how much they enjoy the food provided and that choices are always offered. Yercombe Lodge D51_D03_S16660_YercombeLodge_V227888_060605_Stage 4.doc Version 1.30 Page 15 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 standard(s) 16 The home has a complaints process and information available to service users and their families/representatives to ensure their views are listened to. EVIDENCE: The home and the Commission for Social Care Inspection have not received any complaints. Therefore the homes’ complaints process has not been tested. Several staff have undertaken training in the protection of vulnerable adults. Yercombe Lodge D51_D03_S16660_YercombeLodge_V227888_060605_Stage 4.doc Version 1.30 Page 16 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 standard(s) 19, & 26 Service users live in a well-maintained and comfortable environment that is clean, pleasant and hygienic. EVIDENCE: A tour of the downstairs of the home took place. The flooring in the corridor by the respite rooms has recently been changed. Service users’ spoken to in the respite rooms were very happy with their rooms and especially the extensive views from the front of the house. They also felt the home was clean and tidy. Records of maintenance requests were seen. From discussions with service users’ and staff the doors to the respite rooms and from this corridor to the communal areas are very heavy, especially if a walking aid is required. As the doors are fire doors and must be kept closed, service users’ and staff say they are experiencing difficulties when trying to Yercombe Lodge D51_D03_S16660_YercombeLodge_V227888_060605_Stage 4.doc Version 1.30 Page 17 pass through the doors especially with a walking aid or in the case of the staff pushing a wheelchair. The home must address this issue as it limits service users’ independence and could potentially put service users’ and staff at risk. Staff were observed wearing protective clothing when necessary especially when serving service users with their meals and entering the kitchen. Yercombe Lodge D51_D03_S16660_YercombeLodge_V227888_060605_Stage 4.doc Version 1.30 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28 29 & 30 Staff morale is good resulting in an enthusiastic workforce that works positively with service users to improve their whole quality of life. Staff have received training to enable them to meet the needs of the service users. EVIDENCE: Duty rotas were seen as evidence of staffing levels. The home has 4 carers on duty for the morning and 2 carers on an afternoon shift. The night shift has 1 waking and 1 sleep-in staff. The home also provides day care for a number of residents’ from the local community and a several of these have been attending the home for a number of years. This is reflected in the numbers of staff on an early shift. The home has ancillary staff to undertake additional duties. The staff were meeting the needs of the service users’ on the day of the inspection. The home has 2 care staff with NVQ 2 and 3 staff with NVQ 3 training. The home has not appointed any new staff since the last inspection and the Registered Manager is aware of the Care Homes Regulations and the checks required. Yercombe Lodge D51_D03_S16660_YercombeLodge_V227888_060605_Stage 4.doc Version 1.30 Page 19 A training matrix is in place detailing the training staff have received and when training is due. Staff members confirmed that training courses are available to them. Yercombe Lodge D51_D03_S16660_YercombeLodge_V227888_060605_Stage 4.doc Version 1.30 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33 35, 36 & 38 The Registered Manager is competent in running the home and is well supported by the senior staff. The home now regularly reviews aspects of it performance through a programme of self-review but there was no evidence that service users views are taken into account. Systems are in place to safe guard service users’ financial affairs and to protect the health, safety and welfare of both service users’ and staff. Procedures need to be put into place to ensure staff are appropriately supervised and continue to meet service users’ needs. EVIDENCE: Both the Registered Manager and Deputy Manager have NVQ 4 Registered Manager award and undertake training courses. Yercombe Lodge D51_D03_S16660_YercombeLodge_V227888_060605_Stage 4.doc Version 1.30 Page 21 Service users’ and staff confirmed that the Registered Manager was approachable and friendly. The Registered Manager is well supported by the Deputy Manager and from talking to staff they all demonstrated awareness of their roles and responsibilities. The home now has a quality assurance procedure in place with regular meetings and actions planned to address any issues raised. The home has service users’ comments cards but no regular ongoing process of obtaining service users views’. The home has facilities for managing service users monies and is aware that records need to be obtained. The Registered Manager is not an appointee or agent for any service user. Formalised staff supervision is not taking place, however the Registered Manager has plans to address this. Evidence was seen of serving of equipment and boilers. Monthly checks are undertaken on water outlets to reduce the risk of Legionella and scalding to service users’. Risk assessments are in place for the environment and for the risk of fire. Yercombe Lodge D51_D03_S16660_YercombeLodge_V227888_060605_Stage 4.doc Version 1.30 Page 22 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 2 COMPLAINTS AND PROTECTION 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 2 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 4 3 2 x 3 2 x 3 Yercombe Lodge D51_D03_S16660_YercombeLodge_V227888_060605_Stage 4.doc Version 1.30 Page 23 no 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 7 Regulation 15 Requirement The Registered Person must ensure that service users care plans are individualised to meet their needs. The Registered Person must ensure that records are maintained of the alternative menu choices offered. The Registered Person must fit suitable self closure devices to the doors off the respite corridor leading into the communal lounge/dining room and to service users rooms as the need arises. The Registered Person must ensure that their quality assurance systems take into account the views of service users and their represenatives. Records of these must be maintained. The Registered Person must ensure that staff are appropriately supervised. Timescale for action 1/9/05 2. 15 Schedule 4(13) 23(4a) 30/6/05 3. 19 1/10/05 4. 33 24(3) immediate and onging 5. 36 18(2) 1/9/05 Yercombe Lodge D51_D03_S16660_YercombeLodge_V227888_060605_Stage 4.doc Version 1.30 Page 24 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. Refer to Standard 7 33 Good Practice Recommendations The home should record in service users care plans for example, if one carer is needed for personal care. The tasks the carer needs to perform must be listed. The home should give questionnaires to service users and their relatives once their respite care has finished, asking them for views on the home and anything that would make their stay any better. The home should collate the results of servcie users questionnaires and produce an action plan to address any issues. These should be used as part of the homes quality assurance systems as evidence the home is taking into account service users views. Staff should receive 6 supervision sessions a year. 3. 33 4. 36 Yercombe Lodge D51_D03_S16660_YercombeLodge_V227888_060605_Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester GL3 4AB 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 Yercombe Lodge D51_D03_S16660_YercombeLodge_V227888_060605_Stage 4.doc Version 1.30 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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