Inspection on 13/06/06 for Bullsmoor Lodge

This inspection was carried out on 13th June 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Bullsmoor Lodge 30/04/08

Bullsmoor Lodge 30/04/07

Bullsmoor Lodge 12/01/06

Bullsmoor Lodge 19/09/05

Bullsmoor Lodge 31/01/05

Bullsmoor Lodge 11/05/04

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

CARE HOMES FOR OLDER PEOPLE Bullsmoor Lodge 35-49 Bullsmoor Lane Enfield Middlesex EN3 6TE Lead Inspector Tony Brennan Key Unannounced Inspection 13th June 2006 10:00 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 Bullsmoor Lodge DS0000010662.V292079.R01.S.doc Version 5.1 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. Bullsmoor Lodge DS0000010662.V292079.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Bullsmoor Lodge Address 35-49 Bullsmoor Lane Enfield Middlesex EN3 6TE 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) 01992 719092 01992 650603 BullsmoorLodge@ScimitarCare.co.uk Scimitar Care Hotels Plc Angela Christine Carter Care Home 48 Category(ies) of Old age, not falling within any other category registration, with number (48) of places Bullsmoor Lodge DS0000010662.V292079.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th January 2006 Brief Description of the Service: Bullsmoor Lodge is a modern purpose built home owned by Scimitar Care Hotels. There are four homes belonging to this organisation. The home is registered to care for forty-eight people of either gender who are over the age of sixty-five. Bedrooms are located on three floors. The main lounge, dining room and kitchen are on the ground floor. All but three rooms are single and have en-suite toilets. There is an attractive garden to the rear of the house. There are two lifts that give access to all floors. The home aims to provide support and care in a homely environment. Fees are between £450 and £550. This report is available through the internet. Copies may also be obtained from the provider of this service. Bullsmoor Lodge DS0000010662.V292079.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken as part of the annual inspection programme. The inspector also sought to confirm that the seven areas for improvement identified at the last inspection were addressed. The inspection took place over one day. The head of care, Agust Green, assisted the inspector with part of the inspection. The registered manager was on training on the day of the inspection. The inspector spoke with six people who live at Bullsmore Lodge and four staff. The inspector observed care practice and interaction between service users and staff. The inspector toured the building and examined a number of records relating to the care, health and safety and management of the home. The inspector would like to thank the registered manager and staff who assisted him by answering questions about the running of the home. The inspector would also like to thank those people who live at the home who discussed their views of the service they receive. What the service does well: What has improved since the last inspection? There were seven areas for improvement identified at the last inspection and two of these were met. The administration of all medicines is now recorded. Self-closure devices have been fitted to all bedroom doors where they are needed to ensure the safety of those who live at the home. Bullsmoor Lodge DS0000010662.V292079.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Bullsmoor Lodge DS0000010662.V292079.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Bullsmoor Lodge DS0000010662.V292079.R01.S.doc Version 5.1 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 the following standard(s): 3 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users needs are assessed prior to admission to the home to ensure they receive the care and support they require. EVIDENCE: A service user said, “I have got everything I need here”. The inspector found that service users had been assessed prior to admission. There were assessments from social workers, health professionals and from the home itself. The inspector found that needs identified in initial assessments were not addressed fully in care plans. This is discussed further under standard 7. Staff spoken to understood the needs of individual service users. The inspector observed service users request assistance with personal care. Staff responded by taking time to find out what the servcie users needed support with. Service users files outlined their personal preferences. This included references to their cultural and religious needs. Bullsmoor Lodge DS0000010662.V292079.R01.S.doc Version 5.1 Page 9 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 the following standard(s): 7 8 9 10 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Service users personal, social and medical care needs are not planned for and met. Service users are not fully protected by safe procedures for handling medication. Service users right to privacy is supported. EVIDENCE: A service user said, “carers are all very good to you”. The inspector examined care plans and found that they had not been developed to provide more detail of how the needs of service users would be met. One service user’s file contained a detailed initial assessment that outlined a range of personal, medical and social needs that were not developed in their care plan. Another service user’s care stated that they were “self caring”, but did not outline when and if support might be required from staff. Although one relative confirmed to the inspector that they “had been shown a copy of the care plan”, care plans seen and service users commented they had not discussed or been involved in the development of care plans. There was no record in the care plans to confirm if service users or their representatives were consulted or involved. Care plans had been reviewed regularly. The preferences of service users were recorded. An instance of this was a service user who is catholic, whose Bullsmoor Lodge DS0000010662.V292079.R01.S.doc Version 5.1 Page 10 wish to see the priest was recorded. The service user said, “some staff are catholic, but all are sympathetic and understand my needs”. Service users records showed that they had access to their general practioners and other medical professionals. On the day of the inspection the dentist visited and saw a number of service users. The inspector found that service users risk of falling had still to be assessed and measures to prevent falls identified. A service user with a pressure sore has a risk assessment and care plan. The inspector spoke with the head of care who explained that Waterlow assessments had still to be carried out of service users who may be at risk of developing pressure sores. However, advice is sought from the district nurses when necessary. Records for medication received and administered were complete. The medication policy covered all the areas necessary to ensure detailed guidance on the handling of medication was provided to staff. A record of medication returned to the pharmacist was available. The inspector found that this had not been signed by the pharmacist to confirm receipt of the returned medication. The inspector spoke with the head of care who explained that she and one other senior member of staff had completed training on the administration of medication. Other senior staff are administering medication under supervision. The inspector explained all staff administering medication would need to be trained in safe administration of medication. The temperature of the area where medicines are stored was over 25°c. This was discussed with the Head of Care who agreed to raise this with the home’s pharmacist to ensure that this is safe. Controlled drugs are stored separately and records were double signed. The inspector checked the amount of medication held and this tallied with the record. A service user said “staff don’t interfere with me when I go to my room”. Staff were observed to knock on service users’ bedroom doors before entering. A service user said, “staff understand when to help and when to leave alone”. Bullsmoor Lodge DS0000010662.V292079.R01.S.doc Version 5.1 Page 11 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 the following standard(s): 12 13 14 15 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are provided with sufficient and varied activities to meet their needs. Service users are supported to maintain contact with relatives and other representatives of their choice. Service users are able to make choices about how they live in the home. Service users are provided with varied and balanced meals. EVIDENCE: A service user said, “there are board and ball games and discussions”. The inspector observed staff providing activities and engaging positively with service users. There were photos of recent events and posters advertising entertainment that will take place in the next month. A relative said “staff are welcoming when I come to visit”. The inspector observed staff talking with relatives and both parties appeared at ease. A service user said that staff “ask what I want”. Another service user commented about the food provided that there is always an alternative choice if you don’t like what’s on offer”. The menu showed that a range of meals was offered. A servcie user said “the food is good” and “I can eat what I like, the staff don’t force you to eat”. The inspector saw that meals were well presented and they were provided in a relaxed environment. Sufficient staff were available and when necessary service users were observed being assisted to eat. Bullsmoor Lodge DS0000010662.V292079.R01.S.doc Version 5.1 Page 12 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 the following standard(s): 16 18 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are confident that their complaints will be listened to, taken seriously and acted upon. Service users are protected from abuse. EVIDENCE: A service user said, “I can tell them what I don’t like and they will do something about it”. The complaints policy explained how to make a complaint and how it would be dealt with. This was displayed around the home. A service user said, “if there is something wrong I can go to the manager.” The complaints record showed actions taken to resolve complaints. Service users said that they felt safe and could approach staff if they had any concerns regarding how they are treated. A service user said, “I feel safe here”. There were comprehensive policies on handling abuse and protection. Staff spoken to were clear about the signs of abuse and how suspected abuse should be handled. Bullsmoor Lodge DS0000010662.V292079.R01.S.doc Version 5.1 Page 13 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 the following standard(s): 19 26 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users live in a safe and comfortable environment. The home is a clean and hygienic environment for service users to live in. EVIDENCE: The inspector toured the building and observed that service users bedrooms are personalised. Bedrooms now have self-closure devices fitted where the service user chooses to keep their bedroom door open. A number of bedrooms have been redecorated. The head of care explained that one bedroom would have a new carpet fitted. The inspector saw that the 1st floor hallway had been redecorated. The environment was adapted to the needs of service users with raised toilet seats, bath hoists and a lift in place. The inspector observed that service users were able to move around the building, as they wanted to. The inspector found that the home was clean and hygienic. Guidance and procedures were in place to prevent cross infection. Staff spoken to understood how to prevent cross infection. Protective clothing and hand washing facilities are available to staff throughout the home. Bullsmoor Lodge DS0000010662.V292079.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 30 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Sufficient staff are available at all times to meet service users needs. Staff do not have the skills to meet all the assessed needs of service users. Service users are protected by the home’s recruitment practices. EVIDENCE: A service user said, “care staff are very good and friendly”. The inspector observed that there were sufficient staff available to ensure that service users in all parts of the home were supported. The rota showed that a consistent staffing level was maintained. The head of care explained that when necessary, extra staff are brought in to cover escorting service users to hospital and other appointments. The inspector examined staff records and talked to staff about training they had received. The inspector found that staff had received training on all the areas of statutory required training with the exception of food hygiene and first aid. The inspector also found that staff had received training in a number of areas relating to meeting the needs of service users. These included training on dementia, tissue viability and bereavement. The head of care explained that 50 of staff have achieved the National Vocational Qualification in care at level 2. Staff and training records confirmed this. A number of staff have also achieved the National Vocational Qualification in care at level 3. The inspector examined staff records, which contained all the required information. Bullsmoor Lodge DS0000010662.V292079.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 32 35 36 38 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The registered manager does have the necessary qualifications to manage the home effectively and in the best interests of service users. Service users are routinely consulted about the running of the home. However, the Quality Assurance system is not in operation for service users to comment on the quality of the service provided or to to make suggestions for improvement. Service users financial interests are protected by the home’s procedures. Staff are not supervised to ensure they are supported to meet the needs of servcie users. Service users and staff are protected by the home’s health and safety procedures. EVIDENCE: A service user said, “the manager is easy to talk to”. Staff spoken to also confirmed that the registered manager was approachable and had an open door policy so staff were always able to discuss issues that might arise. The registered manager is working towards the Registered Managers Award. Bullsmoor Lodge DS0000010662.V292079.R01.S.doc Version 5.1 Page 16 The home has a system in place to consult with service users and other stakeholders about the quality of the service provided. The head of care informed the inspector that a survey of the views of stakeholders about the quality of the service still needs to be completed. The inspector saw minutes of meetings that had been held with service users and relatives to discuss issues. The home also has an effective complaints system for service users and their representatives to raise issues. Each service user has a separate account and any expenditure is recorded. The home does hold small amounts of cash for service users. These were checked and found to tally with the records seen. Discussion with the staff and supervision notes showed that some staff had had supervision. Not all staff had been supervised and there were gaps in the supervision records. Service users interests were not supported due to the lack of support provided to staff. Fire drills were taking place. The inspector questioned staff on the fire safety procedures and found that they understood fire safety issues. All health and safety policies were available. Certificates for gas, legionella and electrical testing were in date. COSHH guidance was in place and chemicals were stored safely. Records showed that staff had received training on health and safety topics that ensured that they followed safe working practices. The inspector discussed health & safety issues with staff and they demonstrated their understanding. The home has an effective system for monitoring accidents and this highlights any recurrent issues. Bullsmoor Lodge DS0000010662.V292079.R01.S.doc Version 5.1 Page 17 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 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 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 3 Bullsmoor Lodge DS0000010662.V292079.R01.S.doc Version 5.1 Page 18 Yes 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 OP7 Regulation 15(1) Requirement The registered persons must ensure that care plans have sufficient information on the action to be taken to meet the needs of service users. (The timescale of 01/04/06 was not met). The registered persons must ensure that service users and their representatives are consulted about the contents of their care plans and that this is recorded. (The timescale of 01/04/06 was not met). The registered persons must ensure that service users at risk of falling are assessed and where they are at risk a prevention plan is put in place. (The timescale of 01/04/06 was not met). The registered persons must ensure that the pharmacist signs the record of medicines returned by the home. The registered persons must ensure that all senior staff are trained in the safe administration of medication. DS0000010662.V292079.R01.S.doc Timescale for action 01/08/06 2 OP7 15(1) 01/08/06 3 OP8 13(4)(c) 01/08/06 4 OP9 13(2) 01/08/06 5 OP9 13(2) 18(1) 01/11/06 Bullsmoor Lodge Version 5.1 Page 19 6 OP9 13(2) 7 8 OP30 OP33 18(1) 35(a) 9 OP36 18(2) The registered persons must ensure that medication is stored at a temperature below 25°C. The pharmacist must be consulted if the medicines are stored at a temperature that exceeds 25°C. The registered persons must ensure that training is provided on first aid and food hygiene. The registered persons must ensure that a survey of service users, relatives and professionals is carried out to determine their views of the quality of the service provided. An action plan must be prepared for any areas of improvement identified in the survey. (The timescale of 01/04/06 was not met). The registered persons must ensure that all staff receive supervision at least six times a year. (The timescale of 01/01/06 was not met). 01/08/06 01/10/06 01/08/06 01/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Bullsmoor Lodge DS0000010662.V292079.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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. 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