Inspection on 05/05/05 for Addlestone Lodge

This inspection was carried out on 5th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Addlestone Lodge 19/10/06

Addlestone Lodge 08/08/05

Addlestone Lodge 04/08/04

Addlestone Lodge 18/05/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Addlestone Lodge Ongar Hill Addlestone Surrey KT15 1BS Lead Inspector Mr D Ramdas Unannounced 5th May 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Addlestone Lodge H58_s17657_Addlestone Lodge_v220546_050505_stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Addlestone Lodge Address Ongar Hill Addlestone Surrey KT15 1BS 01932 846268 01932 847197 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Addlestone Care Home Ltd T.B.C. Care Home 25 Category(ies) of OP - Old Age (25) registration, with number of places Addlestone Lodge H58_s17657_Addlestone Lodge_v220546_050505_stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Nursing care for elderly people from the age of 60 years. Date of last inspection 4th August 2004 Brief Description of the Service: Addlestone Lodge is a nursing home for older people situated at Ongar Hill, Addlestone in Surrey. Addlestone Lodge is owned by Addlestone Care Homes Limited and is registered for 25 beds. The home has accommodation which is on three floors and provide single and shared bedrooms. There are lounge areas, dining areas, kitchen, laundry, and bathing and washing facilties. The home is being extended into the back garden and as a result there is limited access to service users. However, the home has a well maintained patio area which is easily accessible and which service users can use. There is adequate private parking for staff and visitors to the front of the property. The home is near to local shops, pubs, churches and other public amenities. Addlestone Lodge H58_s17657_Addlestone Lodge_v220546_050505_stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out by two inspectors over a period of eight hours. A full tour of the premises took place, staff, service users and relatives were spoken to and care records and other documents were inspected. What the service does well: What has improved since the last inspection? What they could do better: The home should look to provide clear leadership to the staff team and to ensure management stability and management continuity by appointing a manager. A cleaner should be recruited to join the staff team to make sure the home is always clean and presentable for service users. The home must improve record keeping and look at more efficient ways of storing records and other documents. The training of staff in dementia care and management of aggression in the elderly must be made a priority. The activities programme for service users must be reviewed with a view to providing more opportunities for community presence. The home must ensure it operates within the category of registration. Addlestone Lodge H58_s17657_Addlestone Lodge_v220546_050505_stage4.doc Version 1.30 Page 6 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. Addlestone Lodge H58_s17657_Addlestone Lodge_v220546_050505_stage4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Addlestone Lodge H58_s17657_Addlestone Lodge_v220546_050505_stage4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4 Service users and prospective service users were provided with details of the services the home provides enabling an informed decision about admission to the home. However they must be improved to ensure service users have up to date and accurate information on which to make decisions. The home should ensure appropriate equipment is provided to meet the assessed needs of service users. EVIDENCE: The home had a Statement of Purpose and Service Users Guide that contained information about how the home operated. It had been reviewed since the last inspection. The Statement of Purpose, Service Users Guide and previous inspection reports were in a binder that was displayed on an occasional table outside the office. One relative had been unaware that inspection reports were openly displayed in the home. It was suggested the binder be placed in a more prominent position in the home. The inspector found The Statement of Purpose needed to be updated to reflect fees and also to amend reference made to NCSC. The inspector found signed contracts on the files sampled. The manager stated, that all admissions to the home were based on a full assessment of needs. This was confirmed from observations. The assessed needs of one Addlestone Lodge H58_s17657_Addlestone Lodge_v220546_050505_stage4.doc Version 1.30 Page 9 service user could not be fully met due to access to her bedroom being inadequate for the use of a hoist that is essential to meet her needs. Addlestone Lodge H58_s17657_Addlestone Lodge_v220546_050505_stage4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8 The health needs of service users are met with evidence of other health care professionals being involved on a regular basis. However, the review of care plans and risk assessments must be undertaken regularly to ensure they are appropriate to the needs of service users. EVIDENCE: The manager stated care plans were in the process of changing to a new improved system. In the meantime it is essential that current care plans and risk assessments are up to date. Care plans should be reviewed monthly and risk assessments should be reviewed more frequently. The inspector found bed rail risk assessments were not adequate and a system for obtaining consent for their use should be implemented. There was a need to develop a protocol for administration of some medication in consultation with the general practitioner. Staff had been overheard to be caring in their approach towards service users. A relative who visited the home regularly for a number of years said her relative was well cared for and looked after at the home. One service user who spent time by choice in her bedroom described the staff as very good. She remarked, they pop in to chat to me and keep me company. The inspector found the management of pressure area care good. Observations confirmed prevention of pressure sore risk assessments were in place including assessment of skin, nutritional status and analysis of mobility needs. There Addlestone Lodge H58_s17657_Addlestone Lodge_v220546_050505_stage4.doc Version 1.30 Page 11 was evidence that advice was sought from a Tissue Viability Nurse and that a registered nurse carried out wound assessments and dressings. The home had a range of aids including airflow overlays and mattresses, air flow cushions and other pressure relieving cushions. Addlestone Lodge H58_s17657_Addlestone Lodge_v220546_050505_stage4.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,14,15 Social activities should be improved to offer opportunities to enrich the lives of service users. Dietary needs of service users are well catered for with a balanced and varied selection of food available that meet service users tastes and choices. EVIDENCE: The inspector observed positive interactions between individual staff members and service users. One service user stated she enjoyed an exercise session and wished this was more often, she further remarked she disliked television and it was on all day. Individual service users stated they were bored and would like to go on excursions. Social care needs were identified in care plans but observations concluded this was an area of the home’s operation in need of further development. The inspector noted the management were exploring the hire of transport to offer opportunities for service users to engage in local, social and community activities. However, there was a need to review social needs and for further development of the programme of activities. Bedrooms were well presented, comfortable and personalised. The home had a written menu that was viewed. Service users were offered opportunity for choice of food at breakfast time. The mid-day meal did not give a choice of menu though special dietary needs and known dislikes were met. During the inspection it was observed that the meals provided on the day had been well prepared and also well presented. Some service users had their meals in the dining area others had their meals in their bedrooms by choice. Addlestone Lodge H58_s17657_Addlestone Lodge_v220546_050505_stage4.doc Version 1.30 Page 13 Staff behaviour was observed to be appropriate at mealtimes with plenty of interaction. One member of staff sat next to a service user, talked to her, stroked her arm and fed her lunch. Another member of staff was observed to be offering a service user a choice when she refused rice pudding as a dessert. Service users commented, meals were lovely and that the taste of the food was good. One service user praised the home for offering her husband a meal free of charge twice a week when he visited her at the home. The day’s menu was displayed on a menu board but only one of the two dining areas had a menu displayed and sometimes service users were not aware of what was for lunch. Addlestone Lodge H58_s17657_Addlestone Lodge_v220546_050505_stage4.doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 Arrangements for protecting service users are satisfactory safeguarding them from the risk of harm and abuse. Information in the care plan was found to be incomplete. EVIDENCE: During the course of the inspection a service user made a disclosure to the inspector. This was followed up and it was established that a complaint from the service user was investigated under Surrey’s multi-agency adult protection procedures. Observation made of the care plan of the service user confirmed the need to record additional information specific to the gender of care staff involved in this service user’s care. Addlestone Lodge H58_s17657_Addlestone Lodge_v220546_050505_stage4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,23,24,25,26 The standard of the environment within this home is good providing service users with a comfortable and homely place in which to receive care. EVIDENCE: The Operations Manager stated, a development plan to extend the home to provide additional en-suite bedrooms, increase dining and lounge space, additional storage areas and office space was in progress. The Operations Manager confirmed during discussions that a variation application would be submitted to the Commission once planning consent was obtained. On the day of the inspection, the home was found to be generally clean. Staff had followed infection control procedures by wearing gloves when appropriate and also hand washing was observed using an alcohol based hand wash that was provided by the home. The décor of the home was generally good, lounge areas had been pleasantly decorated, bedrooms had been personalised all with matching quilts, curtains and fittings. Some of the bedrooms on the top floor were found to be in need of cleaning. Staff stated the cleaning would be done that afternoon. The home was free from any mal odour. Four service users spoken to stated they liked Addlestone Lodge H58_s17657_Addlestone Lodge_v220546_050505_stage4.doc Version 1.30 Page 16 their bedroom and they were also allowed to spend time in their bedroom when they wanted to. On the second floor the fire door was found not to be alarmed. The low eaves in the ceiling of one bedroom needed to be risk assessed with a view to fit protective covers. The home had a patio area that could be accessed from the lounge and offered service users a place where they could sit. The Operations Manager outlined plans to develop the rear gardens to make it more appealing for service users. Addlestone Lodge H58_s17657_Addlestone Lodge_v220546_050505_stage4.doc Version 1.30 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,30 Only limited progress has been made in addressing staffing problems and as a result service users do not receive consistent care. EVIDENCE: The manager stated there had been significant staff turnover. A care assistant reported frequent staff shortages, particularly at weekends, sometimes working with only 2 care assistants for much of the shift until the arrival of agency staff. The manager and operations manager confirmed the accuracy of this information during discussions with the inspector. At the time of the inspection, the home did not have a full time cleaner. The operations manager stated, the post had been advertised. The kitchen assistant has assumed additional responsibilities for cleaning the home five days a week plus half a day on Saturdays. The company employed a training officer present on the morning of the inspection. Discussions with individual staff confirmed a staff training programme was in place and ongoing. The manager and staff confirmed the programme did not include staff training to ensure the needs of people with dementia and aggression are understood and managed. Addlestone Lodge H58_s17657_Addlestone Lodge_v220546_050505_stage4.doc Version 1.30 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,33,37,38 The arrangements for the management of the home must be strengthened to ensure management stability in order to safeguard practice and the welfare of service users. The home must ensure it complies with the conditions of registration. EVIDENCE: Observations confirmed that the home was operating in breach of its categories of registration for reasons of both admissions outside the home’s categories and changes in need. One service user had a physical disability and three were recorded to have dementia on the handover report. The inspector was informed that the manager had tendered her resignation and would leave her post by mid April 05. A member of staff described the lack of management stability as unsettling and also it was difficult to adjust to the different management styles. Some members of staff stated, the current manager had made improvements to the home, others made no comment about the manager. The inspector was informed that the registered manager from the company’s second home in Surrey would be transferred to Addlestone Addlestone Lodge H58_s17657_Addlestone Lodge_v220546_050505_stage4.doc Version 1.30 Page 19 Lodge. The operations manager stated, an application for registration would be made. The operations manager stated service users satisfaction questionnaires were being developed as part of the quality assurance of the home. Regulation 26 (monthly visits by the Responsible Individual) visits were undertaken. Record keeping was fragmented with some records held in the office, others in a lockable trolley and locked filing cabinet in a communal area. Business records and sensitive confidential information was securely stored in a vacant bedroom currently used as an office base for the operations manager. Observations confirmed that hard copies of notifications sent electronically were not kept by the home. It was understood to be the practice of emailing this information to the Commission. The operations manager was requested to ensure email notifications only be sent to CSCI Eashing Enquiries email address with a request for this to be forwarded to the named inspector. Training for staff must include dementia training and management of aggression in the elderly. Addlestone Lodge H58_s17657_Addlestone Lodge_v220546_050505_stage4.doc Version 1.30 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 3 3 2 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 2 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 x 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 2 2 x 3 x x x 3 2 Addlestone Lodge H58_s17657_Addlestone Lodge_v220546_050505_stage4.doc Version 1.30 Page 21 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP 1 Regulation 4(1)(3) Requirement For the statement of purpose to be updated to reflect the new scale of fee charges and amend references made to NCSC. For care plans and risk assessments to be maintained up to date during the transition period whilst implementing the new care planning format. For a bed rail risk assessment to be developed. For the urgent review of the provision of hoists to ensure needs are met. For the staff training programme to include training in dementia awareness, person centred dementia care, management of aggression in older people. A protocol for the administration of rectal diazepam must be in place drawn up in consultation with the general practitioner, providing clear instructions in what circumstances this should be administered. For further development of the activities programme in consultation with service users to meet needs and make arrangements to enable them to Timescale for action 01.07.05 2. OP 4,7. 12(1)(a) (b)13(4) (c) 01.07.05 3. 4. OP 4,22. OP 4,30. 13(5) 18(1)(a) 01.06.05 01.08.05 5. OP 9 (2) 01.08.05 6. OP 12,13. 16(2)(m) (n) 01.08.05 Addlestone Lodge H58_s17657_Addlestone Lodge_v220546_050505_stage4.doc Version 1.30 Page 22 7. 8. OP 27 OP 27,31 9. OP31 10. OP 31 11. OP 38 12. OP 38 13. OP31 engage in local, social and community activities. 18(1)(a) For a cleaner to be employed 23(2)(d) seven days a week. 18(1)(b) That adequate numbers of suitably qualified and competent staff are on duty in the home at all times. 10(1) The home must not operate outside its condition of registration. An application of variation to the homes categories of registration must be made to include additional categories that reflect the assessed needs of the service users currently accommodated. 37(1)(2) That all incidents notifiable under Regulation 37 are reported to the Commission without delay. A hard copy of notifications sent electronically must be held on file available for inspection. 13(1)(b) For a risk assessment to be (c) carried out relating to risks to 23(1)(a) residents accommodated on the second floor specific to the fire door leading to a fire escape. The findings of this risk assessment must be used to inform decisions about fitting an alarm to this door. Consultation should take place with the Fire Safety Officer on this matter. 13(4)(a) For a risk assessment to be (b)(c) carried out for the low eaves in the ceiling in one bedroom on the second floor and where necessary it be fitted with protective covers. 9(1)(2)(a) An application is to be submitted (b)(i)(ii) for registration of the new (c)(i) manager. 01.08.05 01.06.05 01.07.05 01.07.05 01.08.05 01.08.05 01.07.05 Addlestone Lodge H58_s17657_Addlestone Lodge_v220546_050505_stage4.doc Version 1.30 Page 23 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 OP 15 OP 31 Good Practice Recommendations For a menu to be displayed in both dining areas and a system put in place for informing residents of the days menu. Noting that an application for variation of numbers is imminent subject to securing planning approval, it was suggested that this was a timely opportunity to review future requirements relating to categories of registration. It is essential to ensure the application is supported by evidence of suitability of the services and facilities to meet the needs of service users within the categories. To forward a copy of the action plan for future management of the home. For reports of statutory visits carried out by the responsible individual in accordance with the regulations to be sent to the commission. For a review of storage of records in communal areas. 3. 4. 5. OP 31 OP 33 OP 37 Addlestone Lodge H58_s17657_Addlestone Lodge_v220546_050505_stage4.doc Version 1.30 Page 24 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Addlestone Lodge H58_s17657_Addlestone Lodge_v220546_050505_stage4.doc Version 1.30 Page 25 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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