Latest Inspection
This is the latest available inspection report for this service, carried out on 5th March 2010. it is an annual review prepared by CQC after examining previous reports and information from the provider. At the time of this report, CQC judged the service to be Good.
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.
For extracts, read the latest CQC inspection for Feltwell Lodge.
Annual service review
Name of Service: Feltwell Lodge The quality rating for this care home is: The rating was made on: two star good service 0 9 0 2 2 0 0 9 A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection We do an annual service review when there has been no key inspection of the service in the last 12 months. It does not involve a visit to the service but is a summary of new information given to us, or collected by us, since the last key inspection or annual service review.
Has this annual service review changed our opinion of the service?
No You should read the last key inspection report for this service to get a full picture of how well outcomes for the people using the service are being met. The date by which we will do a key inspection: Name of inspector: Dragan Cvejic Date of this annual service review: 2 9 0 1 2 0 1 0 Annual Service Review Page 1 of 6 Information about the service
Address of service: Lodge Road Feltwell Thetford Norfolk IP26 4DR 01366728282 01366727361 feltwelllodge@aol.com Telephone number: Fax number: Email address: Provider web address:
Name of registered provider(s): Conditions of registration: Category(ies) : dementia old age, not falling within any other category Mrs Sandra Elizabeth Hanley,Mr Thomas Paul Hanley Number of places (if applicable): Under 65 Over 65 0 0 8 15 Have there been any changes in the ownership, management or the No service’s registration details in the last 12 months? If yes, what have they been: Date of last key inspection: Date of last annual service review (if applicable): Brief description of the service Feltwell Lodge is a care home providing personal care and accommodation to twentythree Older people, eight of whom may have dementia. The Victorian house is set in five acres of landscaped gardens, surrounded by woodlands and provides a peaceful location in which to live. The home is situated on the edge of Thetford forest and is two miles from the village of Feltwell. It consists of a two-storey building, with accommodation on the ground and first floor. There are four shared rooms, fifteen single, seven with en-suite. There is a passenger lift and stairway for access to the first floor. 0 9 0 2 2 0 0 9 Annual Service Review Page 2 of 6 Service update since the last key inspection or annual service review:
What did we do for this annual service review? We looked all the information we had received, or asked for, since the last Key Inspection carried out in February 2009. This included: An Annual Quality Assurance Assessment (AQAA) form. The AQAA is a self-assessment completed by the Provider and the registered manager, which focuses on how well the Provider considers they are meeting the outcomes of people using the service. It also provides information about the service and how they may be intending to improve over the next 12 months. Information from this document has been used in this report where possible. We consulted the owner/manager on 28/01/2010 for an update on previous requirements. We also looked at information received by us, the regulator, since the last inspection in the form of Notifications. These forms are required to be submitted to the regulator to advise of any issues/incidents that may have happened within the home that may affect the residents welfare. Questionnaires were sent to the service to distribute between residents, relatives and staff. At the time of writing the report 10 service users, 7 relatives and 7 staff questionnaires had been returned. Where possible information and comments from these questionnaires have been included in this report. What has this told us about the service? This review has not changed out opinion of the service and it is concluded that Feltwell Lodge is still providing positive, good outcomes for people who use it. There were no events that would trigger an early full inspection of the service and the home continued to provide appropriate care to service users. Changes that affected service users were reported in a timely fashion to us, the regulator. A few accidents had been reported, together with the homes plan how for to prevent similar events happening again and the actions taken following each individual incident. The home accommodated 22 service users at the time of their AQAA submission, in December 2009. They dealt with 1 complaint and 2 investigations of Adult Protection issues that did not result in referrals to protection of Vulnerable Adults register. Progress of the home was presented in the returned AQAA, (Annual Quality Assurance Assessment) and included: - The Home has updated the Homes policies and procedures to produce the best end result possible for the Homes clients. - Care planning is based on the Person Centred Care Approach developed by the Bradford Dementia Group. Care plans focus on social and emotional needs as much as medical. - The care manager is working with the key workers to enable them to: focus on the clients perceived outcomes of their care at the monthly evaluation session, to document this accurately and to report relevant issues to the care manager. The new care plan system facilitates these aims as they incorporate all aspects of care in a readily available format i.e. waterloo scale, must, risk assessments, dependency status, life history and a detailed plan of care etc. Annual Service Review Page 3 of 6 - Care staff have focussed on developing their skills and knowledge regarding communication with those clients who have difficulties. All staff working towards an NVQ in Care completes the communication unit. At care plan reviews the key workers regularly discuss with the client the clients rights such as the right to vote. - The registered manager has made it a priority that care staff ensures clients personal aids such as hearing aids and spectacles are maintained to a high standard. - The registered manager has introduced a system for Email communication with the clients families. The benefit of this system is the speed with which I can contact family members or answer questions and queries. Feedback form relatives have been very positive. - The cook and the registered manager have reviewed all the menus. The clients opinions were canvassed and the menu options changed where necessary. - The Homes fire policies and procedures have been reviewed and updated and regular evacuation drills are being held. - We have appointed an Operations Manager this year who has been meeting with and costing the homes suppliers as well as investigating staff usage of products and how best to make savings while not affecting the level of care that we provide. The home carried out their own analysis of the achieved standards and reported the findings of their quality assurance outcomes: Last years annual quality audit recorded an overall rating of 99 , a very high standard of quality care is consistently achieved. The client satisfaction survey from last year also recorded an overall rating of 99 , a very high standard of quality care is achieved. Finally The relative satisfaction survey recorded the same overall statistics with an overall rating of 99 . We do not expect these figures to change once this years Annual Quality Audit is carried out. From our own surveys and questionnaires some comments made by the users of the service include: I am quite happy will all care, I have no complaints. I thank God that Feltwell Lodge is my home as I am so well looked after. The relatives responded in the same, positive way: We would like to thank the staff for not only looking after our mother so well, but also for taking care of Maxine. We are pleased that mum was able to have her cat and feel that this type of companionship adds to the quality of mums life at Feltwell Lodge Feltwell Lodge is an excellent home. Please, pass on my thanks and admiration to all at Feltwell Lodge for everything they did for my dear mother. Feltwell Lodge has a very pleasant atmosphere, has good entertainment for the residents and always welcome you when you visit at any time. Staff also felt well supported and motivated to do their job. Some of them praised the training, some addressed the outcomes for service users: Feltwell Lodge provides a high standard of care to service users, maintaining dignity of residents at all times. The owner reported that about 10 new vanity units had installed mixing valves to regulate hot water temperature (as requested previously by us the regulators) and that complete installation should be completed by the end of March. The service was recently inspected by the Health and Safety and there were no major shortfalls. Food and Hygiene also found the home appropriate on their recent inspection. Care planning was appropriate and the home made progress in this area as the staff and some relatives noted and appreciated and the AQAA explained: The home ensures each client has an individual plan of care which provides the outline of the care to be delivered. The plan will be drawn up on the basis of a thorough assessment of the
Annual Service Review Page 4 of 6 clients agreed needs, abilities and aspirations. The plan will have stated objectives, with a range of strategies to be used to attain the planed objectives, to allocate responsibilities and set time scales. The plan contains a client centred risk assessment. All clients have a key worker, who is a senior carer, they review the care plan once a month or more frequently if the clients care needs change. If the client agrees we involve family members in the planning. Our clients are always treated with dignity and respect and treated as individuals. With no significant changes in outcomes for service users, apart from the mentioned improvements, and no changes regarding the management, the home was considered to continue to meet the needs of service users and complies with the standers. What are we going to do as a result of this annual service review? There will be no change to the proposed inspection plan. However, the Commission may choose to carry out an inspection at any time, if information received indicates that the service no longer promotes the safety and welfare of the people who use it. Annual Service Review Page 5 of 6 Reader Information
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