Care Home: The Lodge Care Centre

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What the care home does well Medication is well managed at The Lodge, with good support from the local chemist who supplies the medication. The Lodge maintain good links with relatives, and try to make sure relatives are aware of what is going on, through the use of a newsletter, and notice boards in the foyer. The Lodge is clean and well maintained, with a number of comfortable small lounges. Staff training is given a high priority, and a high proportion of the staff are trained to National Vocational Qualification (NVQ) level II in care. What has improved since the last inspection? What the care home could do better: No statutory requirements have been set as a result of this inspection visit, however two good practice recommendations have been made. These relate to a weekly programme of activities being on display within The Lodge, so that service users, relatives and staff know what activities are taking place. All members of staff should receive formal supervision a minimum of six times a year, in line with National Minimum Standards. CARE HOMES FOR OLDER PEOPLE The Lodge Care Centre Bridge Street Killamarsh Sheffield Derbyshire S21 1AL Lead Inspector Rob Cooper Unannounced Inspection 7th April 2008 10:10 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 The Lodge Care Centre DS0000002088.V362135.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. The Lodge Care Centre DS0000002088.V362135.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Lodge Care Centre Address Bridge Street Killamarsh Sheffield Derbyshire S21 1AL 0114 2476678 0114 2476733 thelodge@schealthcare.co.uk www.southerncrosshealthcare.co.uk Southern Cross Care Homes No 2 Limited 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) Christine Cheryl Hearnshaw Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40), Physical disability (2) of places The Lodge Care Centre DS0000002088.V362135.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Lodge Care Centre is registered to provide nursing and personal care for service users whose primary care needs falls within the following categories: Old Age, not falling within any other category (OP) - 40 Physical Disability (PD) - 2 persons aged 50 and above. The maximum number of persons to be accommodated is: 40. 2. Date of last inspection 2nd May 2007 Brief Description of the Service: The Lodge Care Centre provides care for up to forty older persons who may require personal and nursing care and including two persons aged fifty years and above with physical disabilities. It is located within the village of Killamarsh, which is located within Derbyshire on the border of South Yorkshire and the boundary of Sheffield. It is a purpose built home providing a range of facilities, including all single room accommodation, seven of which have en suites. There is a choice of lounge and dining rooms, including a quiet lounge and also kitchenette areas, which service users who are able can access to make drinks and snacks. There are four assisted bathrooms, including specialist bathing and one shower room, together with suitable toilet facilities. Disabled access is provided to all parts of the home, which service users may access, together with suitable aids and adaptations to assist those service users, who may have physical disabilities, including handrails, grab rails and a nurse call system throughout. There is a small garden area to the rear of the home, which has a seating area. Kitchen and laundry services are centralised. An administrator and a team of nursing, care and hotel services staff, together with external management support, support the registered manager. Fees range from £352 to £493.30 per week depending on the level of care service being received. The fees are due to be reviewed within the next month, as part of the annual review, and fees are determined in accordance with individual’s assessed needs and also via contracts between the home and the relevant social services departments for those who are funded via local authority arrangements. The Lodge Care Centre DS0000002088.V362135.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This was an unannounced visit as part of the key inspection process – so that no one at The Lodge knew that the inspection visit was going to take place. The visit took approximately five hours through the middle of the day, with one inspector present. The methods used during this key inspection and visit were to visit The Lodge, where a method called case tracking was used; this involved identifying four service users and looking at their individual files and making a judgement about the quality of care they are receiving, and if their needs are being met. This was followed by a partial tour of The Lodge, looking at the activities on offer, and talking to three service users, one relative and three members of staff about the quality of the service, and their experiences of living and working at The Lodge. During 2007 the Commission for Social care inspection introduced an Annual Quality Assurance Assessment (known as an AQAA) as part of the inspection methodology, this allows care homes like The Lodge to self assess their service. Information provided by The Lodge helped to form the judgements in this report. We also sent out ten surveys asking for views and information to service users, ten to relatives and ten to staff. Of these we did not receive any from service users, six surveys from relatives and none from members of staff, the relative’s surveys helped us with the judgements that we made. The registered manager Christine Hearnshaw provided much of the information during this key inspection visit. On the day of this inspection there were thirty service users in residence. Prospective service users can obtain information about The Lodge direct from the care home, and this would include seeing previous inspection reports prepared by the Commission for Social Care Inspection. In addition information about The Lodge and the services it provides can be found at the following web site: www.ashbournesl.co.uk. The Lodge Care Centre DS0000002088.V362135.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? At the last key inspection four statutory requirements were made relating to: • • • • A revised statement of purpose and service user guide being made available to service users. The external grounds being made safe for service users. The manager of The Lodge being registered with the Commission for Social Care Inspection. The quality assurance system (for monitoring the improvement and quality of The Lodge) to include service users and their relatives. Evidence was seen that all of these statutory requirements had been met. What they could do better: No statutory requirements have been set as a result of this inspection visit, however two good practice recommendations have been made. These relate to a weekly programme of activities being on display within The Lodge, so that service users, relatives and staff know what activities are taking place. All members of staff should receive formal supervision a minimum of six times a year, in line with National Minimum Standards. The Lodge Care Centre DS0000002088.V362135.R01.S.doc Version 5.2 Page 7 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. The Lodge Care Centre DS0000002088.V362135.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 The Lodge Care Centre DS0000002088.V362135.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): 123 Quality in this outcome area is good this judgement has been made using available evidence including a visit to this service. Current and potential service users have access to detailed information about the services on offer at The Lodge. Service users have contracts or a service agreement and they receive an in-depth assessment of their needs before the service is offered, which allows the service users or their families to make an informed decision about whether The Lodge can meet their needs. EVIDENCE: Both the statement of purpose and service user guide for The Lodge were seen during the inspection visit. Both documents contained all of the information, which Care Homes Regulations say that they should, and provide service users and prospective service users with enough information to be able to make an informed choice about living at The Lodge. Discussions with three service users showed that they had been given copies of the service user guide, and copies were seen in the service user’s bedrooms. The foyer at The Lodge has The Lodge Care Centre DS0000002088.V362135.R01.S.doc Version 5.2 Page 10 a great deal of information on display, including the last inspection report, and notice boards for relatives and visitors, which is part of Southern Cross’s philosophy in making information available to service users, relatives and visitors. In addition service users and prospective service users can visit The Lodge’s parent company’s web site at: www.ashbournesl.co.uk, which also gives details of the services on offer, and has a link to The Lodge’s latest inspection report. As part of the case tracking process four service users were identified, and their files were seen, each one contained an agreement from Social Services to fund their placement, and the terms and conditions of residence were contained in the service user guide. Each of the four files that were seen contained a formal assessment of need. The assessments had all been completed in-house, and covered areas such as: the risk of falls, continence, dependency, and nutrition. The evidence showed that the information provided by these assessments had been used to draw up the care plans. In their AQAA The Lodge said: “Where feasible possible, prior to admission a full comprehensive assessment is carried out to ensure service user’s needs can be met at The Lodge Care Centre. Their likes, dislikes, choices & preferences are incorporated into their care plan with a social profile to aid communication with staff. “ National Minimum Standard 6 was not inspected, as the Lodge does not offer intermediate care. The Lodge Care Centre DS0000002088.V362135.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 10 & 11 Quality in this outcome area is good; this judgement has been made using available evidence including a visit to this service. Service users, who live at The Lodge, are having their personal care given and recorded in a professional and caring manner by the staff, which means that service users’ personal and healthcare needs are being met at The Lodge. EVIDENCE: Each of the four service user’s files that were seen contained a plan of care, which identified personal goals and the service user’s needs and how to meet them. Evidence was seen that care plans were being reviewed regularly, and risks had been identified, with risk assessments to accompany individuals care plans. Examples were also seen of service users having signed their care plans to show their agreement, and knowledge of the contents. In their AQAA The Lodge stated: “Care pans are individual and easy to read. Care plans indicate physical, psychological and social needs. within individual care plans can be found review notes by other health care professionals and social workers.” The Lodge Care Centre DS0000002088.V362135.R01.S.doc Version 5.2 Page 12 All of the files that were seen contained health care plans, and these were clear and well ordered. Three residents were asked about seeing the doctor, and they all said that the staff would get them a doctor if they were unwell, and they needed one. In their AQAA The Lodge stated: “All care plans have individual care needs indicated. Client choice wherever possible is encouraged by the care staff. Visiting chiropodist, hairdresser, optician and dentist can be accessed as required or requested by the service user. We work closely with other health care professionals such as dieticians, tissue viability, continence advisor, district nurse and Macmillan Nurse as well as the service user’s GP to proactively assist our service users with their health care needs as well as reactively dealing with any problems that may arise.” A review of the records, documentation and discussions with staff and service users supported this view. A local chemist provides The Lodge with their medication, and discussions with the qualified nurse on duty, indicated that The Lodge receive a good service from the chemist, and that everyone is very happy with the current arrangements. Medication is provided in blister packs by the chemist (a type of monitored dosage system.) An inspection of The Lodge’s medication systems showed that medication is handled safely. Administration records were seen and found to be complete. No service user at The Lodge currently self-medicates. The member of staff administering the medication wears a red tabard which identifies them as administering the medication, and this is good practice as the nurse said they are often distracted or called away to other tasks, and this increases the likelihood of medication errors being made, so the tabard my help to make the process safer. Discussions with three service users, and observation of the staff working with the service users generally showed that the staff treated service users with respect and dignity. This included observing staff knocking on service user’s doors before entering, and speaking to service users in a respectful manner. In their AQAA The Lodge said: “We have staff who speak varied languages. We encourage service users to live life to the full and plan their care with staff according to their needs or requests. Therefore promoting a positive image of ageing. By liaising well with other professionals we hope to promote a healthy lifestyle for our service users irrespective of age, gender, or diagnosis on admission.” Among the comments received from relatives was the following: “The home offers a good standard of basic care. They treat my aunt with respect and do the best they can.” Each of the service user’s files that were seen contained a specific care plan identifying their wishes at the time of their death, and included evidence of involvement from the resident’s families. The Lodge Care Centre DS0000002088.V362135.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 & 15 Quality in this outcome area is good; this judgement has been made using available evidence including a visit to this service. Service users living at The Lodge are offered a lifestyle that reflects their cultural, social and religious interests, and needs, which means that their social care needs are being met. EVIDENCE: The Lodge employs a part-time activity co-ordinator who organises a weekly programme of activities. Discussions with the activity co-ordinator and three residents indicated that there is a varied programme, although a copy of the weeks activities was not on display, and could not be found, when asked for, which suggests that the programme might be open to last minute change, or being cancelled. Discussions with three service users showed a varied response to the activities, with one person saying that they preferred their own company, and did not join in, while a second told me how much they enjoyed the bingo sessions, the third had not been living at The Lodge very long, and was still coming to terms with the range of activities on offer. Comments received from relatives in the surveys included: “When mother first went into the home they didnt seem to do any activities but recently they are now doing things to keep them occupied.” “Although mum hasnt been a resident for long The Lodge Care Centre DS0000002088.V362135.R01.S.doc Version 5.2 Page 14 (5 Months) in the beginning there wasnt much activity for the residents, although I now believe that this is being rectified.” “Patients are not actively encouraged to join in activities.” One relative was spoken with during this inspection visit, and she indicated that she was happy with the care that her relative was receiving saying: “She (her relative) has come on leaps and bounds since she’s been here.” In response to a question about whether she thought her relative was safe, she responded: “Yes, she’s said so herself, she’s very content.” Two residents were spoken with and they said that their families came to see them and the staff were always very good, and made their families very welcome. Southern Cross have a policy of regular relatives meetings to discuss any issues, and plans, and the manager has a weekly surgery for relatives, where they can come in and talk about any concerns. In their AQAA The Lodge said: ‘Relatives meetings are held every two months. A weekly surgery on Wednesday afternoon is also held for any service user or relative wishing to discuss any issues. A communications suggestion box is also available for staff, services users & relatives to use.’ A copy of The Lodge’s newsletter was also seen, which is aimed at service users, relatives and staff, and provides information about activities, staffing appointments and training success and fundraising. During the course of the inspection visit staff were observed to see how they interacted with service users, and whether choices were offered, and this was seen to be a positive experience with choice being offered around drinks and activities. Discussions with staff working in the kitchen identified how choices were made in relation to food, with choices being made and recorded on the day, as many service users have a short term memory problem, and would be unable to remember what choice they had made over any length of time. Discussions with two service users, indicated that they both thought they had control over what time they went to bed, and got up in the morning, and that the staff asked them about refreshments, food and activities. On the day of this inspection visit the choice of meal on offer was roast beef, or homemade quiche with chips, and a vegetarian option as well if any one required. Information related to service user’s preferences and food likes and dislikes was seen also in the kitchen. The food was well presented, and the dining room was attractively laid out with for service users. The dining room is spacious, and staff were available to offer assistance when and where needed. All of the service users spoken with had good things to say about the food at The Lodge with comments such as: “It’s very nice, very tasty thank you.” “Lovely, really very nice.” Among the comments received from relatives surveys were: “My mother seems happy in the home, is always clean and well dressed. Meals are good and varied; in fact mum says shes given too much too eat.” “Menu change is not suitable for the patients in the home.” “They certainly feed them well and they are kept very clean both the rooms and themselves.” The Lodge Care Centre DS0000002088.V362135.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good; this judgement has been made using available evidence including a visit to this service. Service users living at The Lodge are safe, as a result of the policies, procedures and systems that are in place, and service users and their relatives are confident that if they make a complaint this will be taken seriously and dealt with. EVIDENCE: The Lodge has received eleven complaints since the last key inspection in May 2007. A review of the complaints folder showed that the complaints had been dealt with in line with The Lodge’s complaints procedure, with written responses sent to the person making the complaint. Three service users were asked about making complaints; and all three said they had never made a complaint, but knew whom to complain to if they did. One relative said in their survey: “I would first go to the manager. I have never had to make a complaint.” The details of a specific complaint, and a safeguarding issue which had been sent to the Commission for Social Care Inspection was discussed with the manager, and evidence seen that the complaint had been managed by staff at The Lodge and the outcome recorded. The Lodge Care Centre DS0000002088.V362135.R01.S.doc Version 5.2 Page 16 A review of the staff training records in relation to safeguarding adults, and a review of the statistics showed that 90 of the staff team had undertaken this training. The training is aimed at raising staff awareness of abuse, and issues around abuse and through raising those issues, offering service users greater protection against abusive practice, while also making sure that the staff understand the correct policy and procedure to follow if abusive practice is found. The Lodge Care Centre DS0000002088.V362135.R01.S.doc Version 5.2 Page 17 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 & 26 Quality in this outcome area is good; this judgement has been made using available evidence including a visit to this service. Service users living at The Lodge live in a home that is safe, clean, well maintained and comfortable. Service users have their personal possessions around them, which means that they are living in ‘homely’ surroundings that meet their needs. EVIDENCE: A partial tour of The Lodge showed that it was comfortable and well maintained. A requirement set at the last key inspection relating to the uneven slabs outside the front door has been addressed and these have been re-laid. Discussions with three service users showed that they were happy with The Lodge, with among their comments: “It’s very comfortable thank you”, Oh yes, I’ve got a lovely bedroom, very nice, very well decorated,” and “ It’s lovely.” In their AQAA The Lodge said: ‘We provide a homely atmosphere within a safe maintained enviroment. All service users and their families are The Lodge Care Centre DS0000002088.V362135.R01.S.doc Version 5.2 Page 18 encouraged to personalise and make comfortable their own individual spaces within health and safety perameters. All communal areas are bright, and we are awaiting a new carpet for the upstairs dining/lounge area. We have three domestics, two of whom have NVQ II in Housekeeping. A nurse call system is in place throughout the home and specialist equipment to assist service users is also evident within the home. There are televisions and stereo equipment to all lounges and dining rooms, service users also have the choice of having entertainment systems in their own rooms. All bathrooms have equipment to assist less able service users.” Domestic staff were seen cleaning in different parts of The Lodge during the inspection visit, and discussions with a domestic member of staff indicated that there were good systems in place for cleaning, and that The Lodge had a good range and supply of cleaning materials. The building was found to be clean, and smelt fresh. In relation to cleaning The Lodge said in their AQAA: ‘Policies and procedures are insitu for cleaning the environment and removal of waste. Maintainence books, cleaning books for both rooms and kitchen are also kept and monitored monthly by the manager and area manager. All staff are trained in the use of equipment and coshh regulations to maintain safety. A maintainence schedule to upgrade the home is in place and regularly reviewed to see if targets are met. Keyworker system is in place to regularly review service users private areas and ensure cleanliness and tidiness.’ The Lodge Care Centre DS0000002088.V362135.R01.S.doc Version 5.2 Page 19 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 & 30 Quality in this outcome area is good; this judgement has been made using available evidence including a visit to this service. The staff at The Lodge have been recruited in a professional manner, and have been trained to do their jobs. Evidence suggests that staff are competent, which means that the service users are safe, and have staff looking after them who are able to meet their needs. EVIDENCE: The staffing rota and staffing levels for The Lodge were reviewed and this showed that there were enough staff currently employed to meet the service user’s needs. In their AQAA The Lodge said: ‘We have a recruitment programme to ensure suitable persons are employed subject to their CRB/POVA and reference checks. New staff members undergo a comprehensive induction and training programme. Staff are encouraged to undertake NVQ’s and qualified staff extended roles. As company policy supervisions and appraisals are undertaken. Staff have varied levels of expertise and are supplemented by bank staff who know the service users well, this ensures less use of agency as possible. We have a relatively low turnover of staff, with some staff having been at the lodge for nine years.’ The care industry considers National Vocational Qualifications (NVQ) to level II in care to be the basic qualification for staff working in residential care. A review of the staff training records showed that currently there are twenty-one The Lodge Care Centre DS0000002088.V362135.R01.S.doc Version 5.2 Page 20 care staff at The Lodge, of whom there are thirteen staff with NVQ level II qualifications – There are also seven qualified nurses working at The Lodge. It is recommended that a minimum of 50 of the care team are NVQ qualified, and the staff team at The Lodge have achieved this figure. The files of four members of staff were seen, to check that they contained all of the information that would show that staff at The Lodge had been recruited in a safe manner – namely that applicants had filled out an application form, provided two written references and had had a Criminal Records Bureau check. The documentation showed that The Lodge’s recruitment policy and procedure had worked to protect service users. Discussions with three members of staff about their recruitment showed that they had gone through all of the preemployment checks, and had not started working until those checks had been completed. The staff training records showed that The Lodge does have a training plan for its staff, and that staff training and development is given a high priority at The Lodge. The training records and statistics showed that staff were receiving the training to be able to do their jobs. Discussions with three staff members provided additional evidence of the training courses staff had attended, including training in fire safety, dementia and health & safety etc. In their AQAA The Lodge said: ‘Staff training records and statistics showing underpinning knowledge. Policies and procedures insitu and all members of staff have an in depth job description, references and CRB checks. Staff rotas to ensure staff numbers are at a required level.’ The Lodge Care Centre DS0000002088.V362135.R01.S.doc Version 5.2 Page 21 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): 31 33 35 36 & 38 Quality in this outcome area is good; this judgement has been made using available evidence including a visit to this service. The Lodge is a safe, care home with systems for ensuring it’s quality in place. However formal staff supervision needs to be reviewed to ensure service users are safe, and staff are meeting their needs. EVIDENCE: Christine Hearnshaw is the Registered Manager. She is suitably qualified and experienced, and has been judged by the Commission for Social Care Inspection to be a fit person to run a care home. Christine took over as manager of The Lodge approximately one year ago, shortly after the last key inspection. The Lodge Care Centre DS0000002088.V362135.R01.S.doc Version 5.2 Page 22 The Lodge’s quality assurance system relies on questionnaires being filled in by service users, relatives and visitors. Copies of these questionnaires were seen together with evaluation of the results. This information was on display in the foyer for visitors to see. The Lodge have regular service user’s meetings, and also hold regular meetings for relatives, together with weekly ‘surgeries’ for relatives on a Wednesday afternoon, where relatives can meet with the manager to discuss any particular issues. The Lodge have a system for service user’s small cash needs. This is operated on behalf of some of the service users by the staff (dependent on service user’s choice and their ability to manage the money, or relative’s involvement). Four service users finances were checked at random. All of the cash tallied with the records, and receipts were seen, which enabled a clear audit trail of service user’s financial expenditure to be followed. The Lodge has a formal staff supervision system in place, in which staff receive supervision, either with the manager or with one of the other senior members of staff. This is usually in a one to one meeting. Formal supervision offers staff support and guidance in carrying out their work, and is seen as an essential management tool in residential care. National minimum standards suggest that a minimum of six sessions a year should be held for every member of staff. A review of four staff members’ supervision records showed that this has been inconsistent, and the minimum of six sessions a year has not been achieved. In their AQAA The Lodge said: ‘Supervisions of staff and appraisals are also undertaken regularly as are counselling sessions as required.’ A range of health & safety records were seen, including the fire safety records, water temperature checks and the Control of Substances Hazardous to Health (COSHH) records, all were found to be correct and up-to-date, which shows that the service users and the staff are living and working in a safe environment. The Lodge Care Centre DS0000002088.V362135.R01.S.doc Version 5.2 Page 23 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 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 2 X 3 The Lodge Care Centre DS0000002088.V362135.R01.S.doc Version 5.2 Page 24 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. Standard Regulation Requirement Timescale for action 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 OP12 OP36 Good Practice Recommendations A weekly programme of activities should be displayed within The Lodge, and accessible to service users. All members of staff should receive formal supervision a minimum of six times a year. The Lodge Care Centre DS0000002088.V362135.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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. Extracts may not be used or reproduced without the express permission of CSCI The Lodge Care Centre DS0000002088.V362135.R01.S.doc Version 5.2 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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