Care Home: Godden Lodge

What the care home does well Godden Lodge provides people wishing to use their services with good information; the Statement of Purpose and Service User Guide describes the service well. The home has a good assessment process and people receive a thorough assessment of their needs before they move into Godden Lodge. The care planning process is good; each person has a care plan that is developed from the initial pre-admission assessment and it is kept under review at frequent intervals. The home has employed staff specifically to arrange activities for the people living in Godden Lodge and people said that they were happy with these. Godden Lodge provides people with good healthcare; the records showed that people received the help and support that they required when they required it. People are encouraged and supported to complain if they wish to do so and the home has a good complaints system that has recently been computerised. Godden Lodge employs staff to carry out minor maintenance tasks and any repairs are carried out promptly. The buildings and grounds are well maintained and Godden Lodge has a clean and hygienic homely atmosphere. The staff at Godden Lodge are well trained. Godden Lodge has a good quality assurance system which includes regular audits by the management team and an annual customer satisfaction survey. What has improved since the last inspection? Staffing levels on Cephus have improved; there are now two qualified members of staff and at least three care assistants on duty throughout the day. Godden Lodge has a clear system for dealing with people`s money and records are securely stored on the home`s computer system. The process is now clearly explained in the Service User Guide. What the care home could do better: The Statement of Purpose should provide information about the manager`s qualifications and experience to ensure that people know that the home is run by an experienced, qualified person. People should have access to their emergency call bells at all times to enable them to call for assistance if they need it. If there are people that are not able to use their emergency call bell, this should be clearly recorded in their care plan, which should provide details of what other measures are in place to address the issue. The maintenance records should show the date that any repairs are carried out to ensure that they are done so in a timely manner. The staffing hours on Cephus House should be reviewed as many staff are working fifty to sixty hours each week continually which may make them overtired. The home should have a minimum of 50% of care staff trained to NVQ level 2 in care or above. The organistaion should recruit and register a manager so that a qualified and experienced person is running the home on a daily basis. All staff working at Godden Lodge should receive at least six supervisions each year to ensure that they are fully supported to carry out their work. Key inspection report Care homes for older people Name: Address: Godden Lodge 57 Hart Road Thundersley Benfleet Essex SS7 3GL     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home 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 full review a ‘key’ inspection. Lead inspector: Pauline Marshall     Date: 0 5 0 3 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 30 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 30 Information about the care home Name of care home: Address: Godden Lodge 57 Hart Road Thundersley Benfleet Essex SS7 3GL 01268792227 01268565474 warnersu@bupa.com www.bupa.com BUPA Care Homes (CFHCare) Ltd Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Type of registration: Number of places registered: care home 133 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category physical disability terminally ill Additional conditions: People who have a diagnosed physical disability to be nursed on Cedars House only. People who have a diagnosed Terminal Illness to be nursed on Cephas House only and be aged over 40 years. People who have a diagnosis of Dementia to be nursed on Boyce and Murelle House only. Date of last inspection 60 0 10 10 Over 65 60 133 0 0 Care Homes for Older People Page 4 of 30 Brief description of the care home Godden Lodge provides nursing and personal care for up to a maximum of one hundred and thirty three people. The home is situated in Thundersley close to local shops and bus routes. Accommodation is provided within five seperate houses and people using the service have single bedrooms and access to communal lounge/dining rooms and seperate garden spaces. People wishing to live at Godden Lodge are given a copy of the Statement of Purpose and Service User Guide. The weekly fees range between £390.00 to £900.00; there are additional charges for hairdressing, chiropody, newspapers and magazines and toiletries. Care Homes for Older People Page 5 of 30 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This was an unannounced key inspection that lasted for nine and a half hours and was carried out by two inspectors. All of the key standards were inspected; we checked a random sample of policies and procedures and we examined some of the records that the home is required to keep. We looked around the buildings and we spoke to some of the people living in the home, to some of their visiting relatives, to some of the staff and to the regional manager and to the deputy manager. We checked the progress of the requirement and recommendation that was made at the last inspection on 28th March 2008 and we found that they had been met. The interim general manager completed his annual quality assurance assessment (AQAA) and returned it to us within the required timescale; it was detailed and informative and provided us with good information about the service. The AQAA is a self assessment document that the manager is required by law to complete; we have used the information provided in the AQAA throughout this report. Care Homes for Older People Page 6 of 30 We sent surveys to ten people using the service, eight health and social care professionals and ten of the homes staff to obtain their views on the service that the home provides. We received completed surveys from eight people that use the service, three health and social care professionals and ten of the homes staff. They were mainly positive but did show that some people had concerns about staffing levels at times. Comments from the surveys have been included throughout this report. Care Homes for Older People Page 7 of 30 What the care home does well: What has improved since the last inspection? What they could do better: The Statement of Purpose should provide information about the managers qualifications and experience to ensure that people know that the home is run by an experienced, qualified person. People should have access to their emergency call bells at all times to enable them to call for assistance if they need it. If there are people that are not able to use their emergency call bell, this should be clearly recorded in their care plan, which should provide details of what other measures are in place to address the issue. The maintenance records should show the date that any repairs are carried out to ensure that they are done so in a timely manner. The staffing hours on Cephus House should be reviewed as many staff are working fifty to sixty hours each week continually which may make them overtired. The home should have a minimum of 50 of care staff trained to NVQ level 2 in care or above. The organistaion should recruit and register a manager so that a qualified and Care Homes for Older People Page 8 of 30 experienced person is running the home on a daily basis. All staff working at Godden Lodge should receive at least six supervisions each year to ensure that they are fully supported to carry out their work. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 30 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 30 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this 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 get good information about the service and they know that their needs are fully assessed. Evidence: The homes Statement of Purpose and Service User Guide was last reviewed in November 2009 and both documents contained up to date information about the service Godden Lodge provides. The interim general manager said in his AQAA we provide comprehensive written information to all prospective clients. The Statement of Purpose did not provide people with any details about the qualifications and experience of the registered manager as required in regulation; this should be reviewed to ensure that the information is included. Each of the thirteen care files that we looked at contained a fully completed preadmission assessment, which was recorded in the QUEST individual assessment document. This document has provision for four additional assessments to be recorded Care Homes for Older People Page 11 of 30 Evidence: and a further assessment is carried out within a month of admission to ensure that the information the home has is still appropriate to meet the individuals needs. The assessment documentation looks at all areas of health and social care needs such as communication, lifestyle, skin integrity, mobility, mental state, eating and drinking, personal care and end of life arrangements. People spoken with confirmed that they were fully involved in the assessment process and one relative spoken with confirmed that the process was good and involved a visit to the home before admission took place. Godden Lodge does not provide intermediate care. Care Homes for Older People Page 12 of 30 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this 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 receive appropriate individualised care based on identified needs. Evidence: We looked at thirteen care plans and each of them included detailed information on the level of care that people required. In general staff seemed to have a good awareness of peoples individual needs and interacted well. However at the moment quite a lot of agency staff are used which may detract from this, for example a member of staff had to consult a piece of paper to tell us who a resident was. People generally looked well cared for and were appropriately dressed. People seemed happy and relaxed and had a good rapport with staff. One of the care plans that we looked at was that of a person where a mattress is placed on the floor next to the bed. The care plan was generally satisfactory, however, the care plan relating to the persons safety in bed stated XX sleeps well at night but wakes up occasionally. There was no mention in the care plan of the reasons and risks of the mattress being on the floor beside the bed. The care plan went on to state staff to ensure that bedside rails and bumpers are properly in place, also to monitor Care Homes for Older People Page 13 of 30 Evidence: every fifteen minutes (as cannot use the call bell) and reposition every four hours. The person in charge said that the mattress on the floor had been in use for a long time (about a year). The care plan had been reviewed on a monthly basis but had not been updated; the person in charge undertook to do this immediately. We noticed from looking at individual care plans where people had different cultural needs that they provided clear information of how the persons needs were to be met such as hair must not be cut and the family visits daily and they bring in special food. We found that separate sheets are kept in communal files for the recording of bathing, bowel movements and behaviours; this is not good practice as confidentiality could be breached. The deputy manager explained that these records are kept in this manner to allow staff to access them quickly when situations arise, however, we feel that it is not good practice to keep peoples private records in a communal file. One of the care plans that we looked at showed that the person was cared for in bed and that they liked to sleep late in the mornings the care plan was well organised, clear and highlighted personal preferences such as prefers female staff for care interventions. We observed this person and noticed that they did not have access to their call bell; there was no mention of this in the care plan. We also observed other people in their beds with no access to their call bells and their care plans contained varied information such as staff should ensure that the call bell is in reach at all times whilst in bed encourage use of buzzer no buzzer cord in place and another care plan said that XX could not effectively use the buzzer. There were risk assessments and management plans in place for all appropriate areas of care such as tissue viability, continence, falls, bathing, use of equipment, moving and handling and medication. Staff spoken with were clear on the levels of help that people required to manage any identified risks appropriately. We looked at the medication on four of the houses and we found that it was mainly well managed and regularly audited. Each of the medication administration record sheets (MARS) contained clear instructions and there were photographs in place to identify each person. Opened packets and bottles were dated and there was a list of staff that were authorised to administer medication on each of the houses. Godden Lodge has a range of medication policies to cover all areas of practice, and staff spoken with were fully aware of these. Medication was stored appropriately on all five houses in locked trolleys in locked cupboards, which were clean tidy and cool. The training records showed that all staff administering medication had received training. People spoken with said that they felt well treated and we observed staff treating Care Homes for Older People Page 14 of 30 Evidence: people using the service in a dignified manner and talking to them respectfully. The interim general manager said in his AQAA residents care is focused on being person centred, supported by the Personal Best Programme and people spoken with said the staff provide me with all the care that I need and I feel that the care that I get is the care that I need. We witnessed an incident where a person collapsed in a communal area and the staff were quick to act to protect their privacy and dignity by putting up a screen whilst they assisted them. Relatives spoken with confirmed that people were always treated with dignity and respect. Each of the care plans that we looked at contained clear detailed information on the persons wishes at the end of their life. It was clear from the care plans that we looked at that the person using the service and their relatives had been involved in this. Care Homes for Older People Page 15 of 30 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this 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 well supported to live a lifestyle that meets their identified needs and preferences. Evidence: The care files that we looked at showed that people are encouraged to participate in activities on a daily basis. The interim general manager said in his AQAA we have a structured activities plan with dedicated activities co-ordinators and we encourage a weekend activities programme. Each care plan included a lifestyle profile that showed the type of activities that the person enjoyed such as if they liked to mix in a large or small group or preferred to spend time in their own company; it also looked at outside activities such as outings to the pub, garden centre or library. The Map of life document provided a good picture of peoples background, their interests and hobbies and their hopes and dreams for the future. The ones that we looked at varied in their content as some of the information needed to be collected over a period of time from members of the family where the person was unable to provide the information themselves. The activities records showed that people had participated in coffee mornings, an art matching picture game, a therapy doll, music, puzzles, reminiscence, bingo and skittles; there was many pictures of people enjoying a variety of activities displayed around each of the houses. Care Homes for Older People Page 16 of 30 Evidence: Godden Lodge employs activities co-ordinators and when we spoke to one of them and they told us that although some equipment is kept centrally a cupboard is also available on the unit so that staff can access this and carry out activities when the activities co-ordinator is not around. We observed people participating in a reminiscence session, playing skittles, enjoying a music session and playing a game of bingo. In one of the houses we observed people enjoying a manicure and one person told us that they had been for a long walk this morning another person told us that they used the hairdressers in the village. We saw many visitors throughout the day and one person told us that they regularly go out into the local community and that they were about to go to the local supermarket where they would enjoy a coffee and a snack. People using the service confirmed that they are offered a choice of a range of things such as their meals, their clothing and their daily activities. The organisation regularly carries out customer satisfaction surveys and the last one showed that more than 50 of the respondents felt that the choices of food and activities were good. Not all of the houses hold regular residents meetings but staff told us that more meetings were planned and that relatives would also be invited. We looked at the notes of one meeting that took place on 13/12/09 with relatives and carers and this showed that the Christmas party, care plans, staffing levels and the replacement of the homes hairdresser had been discussed. The notes showed that relatives were happy with the standard of care and the staff member informed them that they could approach him at any time if they have any problems. The home offers people a choice from its four rolling menu; the Service User Guide states that people are provided with a menu from which they can choose their meal for the following day. Menus are displayed in each of the houses and there is a night bite menu that is available throughout the night should people require it. We looked at the range of meals offered in the menus and they included old time favourites such as cottage pie, toad in the hole, beef stew and dumplings and roast beef and yorkshire pudding. The menu also provided people with a range of other foods such as sweet and sour chicken, chinese BBQ spare ribs and vegetable curry with naan bread and there was a choice of either a hot or cold dessert each day. The interim general manager said in his AQAA the views of our service users influence menu choices and the 2009 satisfaction survey showed improvements in food and activities. People spoken with and surveyed said the food is very good they do really well with the food here the food is really nice. Staff said in their surveys people get excellent nutrition and the food is really good. Meals are Care Homes for Older People Page 17 of 30 Evidence: cooked in the main kitchen and delivered to the houses in heated trolleys; staff on each house plate up individual meals according to peoples requirements. The food offered was appealing, nicely plated up and sufficient in quantity to meet peoples needs. The training matrix showed that staff preparing and serving meals had received training in food safety. Care Homes for Older People Page 18 of 30 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this 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 know that their concerns will be dealt with and that they will be protected from harm and abuse. Evidence: The home has a clear complaints procedure that was recently reviewed to show the new contact details of the Commission. People spoken with and surveyed were aware of how to complain and there were leaflets containing the procedure displayed in all of the houses. Godden Lodge has introduced a new system for recording all complaints and from July 2009 they are recorded on the homes computer system. We looked at some of the initial complaint records that showed who made the complaint, the date the complaint was made and any actions that had been taken to resolve the issues. Regular audits take place to ensure that all complaints are recorded and dealt with appropriately. All staff have received training in safeguarding vulnerable adults and staff spoken with confirmed that the training was informative. The organisations safeguarding adults procedure was last updated in October 2008 and it provided staff with clear instructions on the actions they must take if they suspected abuse. There has been five safeguarding issues since the last inspection and they have all been dealt with appropriately. Care Homes for Older People Page 19 of 30 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this 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 live in a homely, comfortable safe environment. Evidence: The interim general manager said in his AQAA we have improved all aspects of facilities, maintenance and housekeeping in the past twelve months. We looked around all five houses, Boyce, Cephus, Cedars, Murrelle and Appleton and we found that all were maintained to a reasonably good standard. Some areas were looking a little tired and some of the furnishings (such as chairs in Cedar) are worn and could do with being replaced. Each of the houses has good communal space with large lounge/dining areas with conservatories overlooking the gardens, which have seating and bird tables; there is also a sensory garden. All of the bedrooms are single and are of a good size with en-suite facilities and people spoken with said I am happy with my room, there is plenty of room here and I have all that I need in my room and I have a lovely view, I watch the birds feeding from the bird table. We spoke with a member of staff who worked in the laundry whilst she was returning peoples clothing to one of the houses and it was clear that she had received appropriate training in infection control and health and safety issues. Godden Lodge employs a team of cleaners and the training matrix showed that all have had training in health and safety, infection control and COSHH (control of Care Homes for Older People Page 20 of 30 Evidence: substances hazardous to health). All areas of the home were clean and fresh and there was no unpleasant odours and people spoken with and surveyed confirmed that the home was always clean and fresh. Each of the houses keeps its own maintenance records for minor repair works and the maintenance records showed that work was carried out in a timely manner as the maintenance man ticked and signed to show that jobs had been completed. The maintenance records did not include the date that any repairs had been carried out, however, recent entries had been ticked as work done but if the date of repair was shown in the maintenance records it would be clearer as to when work had been carried out. Care Homes for Older People Page 21 of 30 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported by well trained staff that are safely recruited but the excessive hours worked by some staff could put people at risk. Evidence: We looked at the staff duty roster for Cephus House over a twelve week period and we found that there is generally two qualified nurses plus three care assistants throughout the day and one qualified nurse with two care assistants throughout the night. The duty roster showed that most staff work a twelve hour shift each day and that most of the staff worked additional hours with some qualified staff working between forty-eight and sixty hours each week and that some of these hours were worked at night. The duty roster showed that three care assistants also worked in excess of their contracted forty-two hours a week and that this was constant; over a three week period each of them worked for sixty hours per week; staffing hours should be monitored to ensure that staff are not overtired and working excessive hours. Additional staff are employed to carry out domestic duties, laundry duties and and activities duties on each of the houses. The duty rosters showed that there were sufficient staff on duty to meet the needs of the people using the service, however, many of these were either bank or agency staff and at one point an agency member of staff needed to look up a persons name on a list that they kept in their pocket. The AQAA confirmed that Godden Lodge has used a Care Homes for Older People Page 22 of 30 Evidence: large amount of agency or bank staff in the past three months. We looked at the duty rosters on all four other houses and with the exception of Appleton the staffing levels appeared adequate, although staff spoken with and surveyed often felt that the home was short staffed. There are ten people living in Appleton and there are two staff members throughout the day and one staff member at night. The regional manager told us that this was not appropriate and that this was being addressed and we have been informed by the interim general manager that agency staff will be employed as from now on, until a permanent member of staff is recruited to the post. Eight of the ten staff surveys that we received showed that staff were concerned about the staffing levels at times and their comments included a lot of residents need time spent with them, but staff are always busy and dont get as much time as they would like. Teamwork is good amongst staff even when there is a shortage of staff the home should increase staff levels in high dependent units and we need higher staffing level. One health and social care professional said in their survey staff numbers could be increased at busy times of the day i.e. mornings. Godden Lodge has not met its quota of NVQ trained staff as required in the National Minimum Standards. The Statement of Purpose states that the home is working towards the required minimum of 50 of staff and the AQAA showed that nine of the forty six care staff have attained an NVQ qualification. One health and social care professional said in their survey there is not enough NVQ level 3 carers qualified to look after non-nursing residents. The training records showed that only a small number of staff have attained NVQ levels 2 and 3. The interim general manager said in his AQAA we operate a Personal Best Programme, which encourages staff to provide a truly individual service to people and this has won us the Chartered Institute of Personnel and Development annual people management award. People spoken with confirmed that staff were helpful and their comments included staff are friendly and helpful and they are very nice here. We observed that some staff interacted well but others not so good. People said when spoken with and in their surveys staff are very caring but we could do with more at times, staff are friendly and staff are kind and helpful. One health professional said in their survey staff are kind and caring but I think they could do with more staff at certain busy times of the day such as in the mornings. The interim general manager said in his AQAA we have rigorous recruitment policies and procedures and the eight staff files that we looked at included all of the relevant Care Homes for Older People Page 23 of 30 Evidence: documentation such as a fully completed application form, two written references and evidence of staffs induction. We had sight of three original Criminal Records Bureau (CRB) checks and the top portion of four others; the deputy manager told us that these had been inspected in the past and that the home was advised to destroy the records once inspected. A discussion took place around the requirements of the Care Standards Act to keep the full CRB checks until they have been inspected and the need to hold evidence that this has occurred. The deputy manager provided us with a training matrix prior to the inspection and this showed that staff had received limited training. When viewing the staff files we saw copies of certificates of training in safeguarding adults, food hygiene, health and safety, moving and handling, falls prevention, tissue viability, infection control, first aid and dementia. Staff spoken with confirmed that training was good and all of the staff surveys that we received supported this. The deputy manager has since told us that the training matrix supplied for the inspection was out of date and we have been given an up to date version which confirms that regular training has taken place in the past year. Care Homes for Older People Page 24 of 30 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Whilst the home is generally well run, the unsettled management situation and the lack of staff supervision may not always provide people with the best outcomes. Evidence: Godden Lodge has been without a registered manager since 02/01/2009. There has been three acting managers in post throughout the past year and the most recent manager has not been working in the home since February 2010. Godden Lodge is currently being managed by the deputy manager with support from the regional manager and the interim general manager. The organisation (BUPA) carries out regular Customer Satisfaction Surveys as part of its quality assurance system and a report of the findings is published and shows any actions that are required. The report shows peoples overall satisfaction with the service, it makes a comparison with the last Customer Satisfaction Survey and it includes direct quotes from people using the service and their relatives. The interim general manager said in his AQAA the 2009 customer satisfaction survey shows that Care Homes for Older People Page 25 of 30 Evidence: there has been a 30 improvement in the overall service provided at Godden Lodge. The regional manager carries out monthly visits under Regulation 26 and compiles a report of her findings. The report shows any actions identified and how they are to be met. Supervision sessions are recorded and kept on staff files and the date of the supervision session is entered on the training matrix and this showed that the level of supervision varied. The training matrix showed that supervision has not been carried out as required in the National Minimum Standards and that only one of the thirteen qualified staff had received the six sessions as required. The training matrix showed that of the fifty-four care assistants employed at Godden Lodge six had no supervision, thirteen had one supervision, fourteen had two supervisions and twelve had three supervisions in the past year. Two care assistants received the full six supervisions as required and three had received five supervisions and four had received four supervisions in the past year. Staff said when spoken with that they felt well supported in their work and all ten staff surveys received confirmed that staff felt that the manager gives them enough support. We looked at eight staff files and these showed that supervision had not taken place as often as required in the National Minimum Standards and the regional manager and the deputy manager agreed that it had not. Although the AQAA identified that there are shortfalls in staff supervision, it also showed that all staff are supervised. The AQAA also states that monthly staff meetings are held and we did not see the evidence to support this. Staff spoken with told us that staff meetings were infrequent and supervision was irregular. The regional manager said that steps are being taken to address this issue and that supervision is going to be delegated to senior staff to ensure that the home meets the National Minimum Standards. The regional manager said that this would be monitored on a regular basis to ensure that supervisions are carried out as required. The home does not hold any cash for the people living at Godden Lodge. Money is held in a Post Office account and people request any monies in advance and this is drawn from the post office when required. A record of all monies received is kept on the homes computer system. We looked at a random sample of safety certificates and they were in place and up to date. The home has a fire risk assessment that was last reviewed in March 2008 and fire drills are carried out regularly. Care Homes for Older People Page 26 of 30 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 27 of 30 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 13 The responsible person must 30/04/2010 ensure that people have access to staff assistance when necessary. This refers to the need to either have access to their call bell or where not able to use it a care plan that shows the actions staff need to take. To ensure that the person is kept safe. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 1 It is recommended that the Statement of Purpose includes information on the qualifications and experience of the registered manager to ensure that people know they are being cared for by an experienced and qualified manager. It is recommended that the maintenance records show the date that the work was done to ensure that all repairs are carried out in a timely manner. Page 28 of 30 2 19 Care Homes for Older People Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 3 27 It is recommended that staffing hours be monitored on Cephus House to ensure that staff are not overtired and putting people at risk. It is recommended that staff deployment be reviewed to ensure that there are adequate staff members available when and where needed at busier times of the day. It is recommended that Godden Lodge has 50 of care staff trained up to NVQ Level 2 as required in the National Minimum Standards. It is recommended that the organistion recruits and registers a manager to ensure that there is a suitable experienced and qualified person running the home. It is recommended that all staff receive at least six supervisions each year to ensure that they are fully supported to do their work. 4 27 5 28 6 31 7 36 Care Homes for Older People Page 29 of 30 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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