Inspection on 19/09/05 for Bullsmoor Lodge

This inspection was carried out on 19th September 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 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 13/06/06

Bullsmoor Lodge 12/01/06

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 Unannounced Inspection 19th September 2005 09:00 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.V249308.R01.S.doc Version 5.0 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.V249308.R01.S.doc Version 5.0 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 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.V249308.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st January 2005 Brief Description of the Service: Bullsmore 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. Bullsmoor Lodge DS0000010662.V249308.R01.S.doc Version 5.0 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 process. The inspector also sought to confirm that the eight areas for improvement found at the last inspection were addressed. The inspection took place over one day. The registered manager assisted the inspector. The inspector spoke with five people who live at the home, three relatives and four staff. The inspector toured the building and examined a range of records relating to the care and management of the home. What the service does well: What has improved since the last inspection? 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.V249308.R01.S.doc Version 5.0 Page 6 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.V249308.R01.S.doc Version 5.0 Page 7 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): 134 Services users and prospective service users are provided with comprehensive information about the service. Service users needs are assessed prior to admission to the home. The home does meet all of the assessed needs of service users. EVIDENCE: Service users said that they understood what the home provides. The inspector found that the statement of purpose and service user guide were complete and provided all the required information. Service users commented that staff were caring and helpful. The inspector saw that service users had been assessed before admission and assessments were also received from social workers. Staff spoken to understood and could explain how they met the needs of service users. The care plans were based on the needs identified in the initial assessment and had been updated to include more information on how these would be met. Bullsmoor Lodge DS0000010662.V249308.R01.S.doc Version 5.0 Page 8 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): 789 Care plans provided sufficient information on how the needs of service users would be met, but they had not been consulted about the contents of the plans. Service users health needs are being met. The administration of medicines was not recorded, putting service users safety at risk. EVIDENCE: Service users said that they felt staff were supportive and knew how to help them. Since the last inspection care plans had been updated to provide more information on how the needs of service users will be met. Care plans are being reviewed monthly. Service users and relatives spoken to had not been consulted about the content of care plans. The inspector saw that there was no record of such consultation. Falls risk assessments and care plans were in place outlining the risks and measures for their prevention. The records of medical treatment were detailed and showed that the appropriate medical attention had been provided. There were records of medical interventions. The medicines policy was complete. Records of medicines received and returned by the home were all complete. The inspector examined the records of medicines administered and found that there were gaps. Bullsmoor Lodge DS0000010662.V249308.R01.S.doc Version 5.0 Page 9 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): 15 Service users are provided with a choice of varied and balanced meals. EVIDENCE: Service users commented that the food was good and choices were provided. The menu showed that varied and balanced meals were offered. Service users said they were consulted daily about the choices being offered. The inspector saw that meals were well presented and they were provided in a relaxed environment. The registered manager explained that Italian and Greek service users were provided with meals that reflect their cultural backgrounds. Bullsmoor Lodge DS0000010662.V249308.R01.S.doc Version 5.0 Page 10 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 Service users are confident that their complaints will be listened to, taken seriously and acted upon. Service users are protected from abuse. EVIDENCE: Service users said that they felt confident in making their concerns known to staff. The complaints policy explained how to make a complaint and how it would be dealt with. 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 were treated. 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.V249308.R01.S.doc Version 5.0 Page 11 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 22 26 Service users live in an environment that is adapted to their needs. Service users are safeguarded against cross infection. EVIDENCE: The inspector found that the home was adapted to meet the needs of service users. There were assisted baths and disabled showers. Service users were able to access all parts of the building by the lift. A report had been prepared on the home by an occupational therapist and the recommendations had been implemented as appropriate. The inspector found that the home was clean and hygienic. Staff spoken to understood how to prevent cross infection and equipment was provided for this purpose. Bullsmoor Lodge DS0000010662.V249308.R01.S.doc Version 5.0 Page 12 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 Sufficient staff are available at all times to meet service users needs. Staff do not have the skills to meet all the needs of service users. Service users are not protected by the home’s recruitment practices. EVIDENCE: Service users said that staff were available to meet their needs. The rota showed that seven care staff were on duty in the morning and six in the afternoon. This staffing level was maintained consistently. Three files of new staff were examined and it was found that two of these had no references or POVA/CRB’s. Training records showed that 50 of staff had achieved NVQ in care. Service users felt that staff generally understood their needs. Staff spoken to confirmed that they had been provided with a wide range of training and that they felt well supported by the registered manager. Records showed that training on dementia, handling death and dying and skin care had been provided along with training covering all the required statutory topics. The registered manager was able to confirm that training on care planning had been arranged. Bullsmoor Lodge DS0000010662.V249308.R01.S.doc Version 5.0 Page 13 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): 36 37 38 Staff are not appropriately supervised. Records are maintained that ensure that service users needs are met. Service users and staff safety is not always promoted. EVIDENCE: Staff spoken to said that they had not had regular supervision. The inspector found that records of supervision still showed that supervision was not taking place six times a year. All records seen were up to date and accurate. The inspector found that staff had training on health and safety topics. The necessary records of food temperatures and of the fridge and freezers had been maintained. Gas and electrical certificates were seen and in date. The home had all the necessary policies and procedures in place to ensure the safety of service users and staff. There was a record of accidents. There were records to confirm that the fire safety equipment had received its annual check. The records of drills and weekly testing of the alarm and other fire equipment were in place and showed that testing and drills took place regularly. Training records and discussions with staff confirmed that there was Bullsmoor Lodge DS0000010662.V249308.R01.S.doc Version 5.0 Page 14 regular fire training. The inspector found that doors to a number of bedrooms had been wedged open. This was discussed with the registered manager who agreed to have automatic door closures in place. Bullsmoor Lodge DS0000010662.V249308.R01.S.doc Version 5.0 Page 15 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 X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 3 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 X X X X X 2 X 2 Bullsmoor Lodge DS0000010662.V249308.R01.S.doc Version 5.0 Page 16 Are there any outstanding requirements from the last inspection? Yes 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 service users and their representatives are consulted about the contents of the care plans and that this is recorded. (The timescale of 1/5/05 was not met). The registered persons must ensure that the administration of medicines is recorded The registered persons must ensure that all staff receive supervision at least six times a year. (The timescale of 1/5/05 was not met). The registered persons must ensure that bedroom doors are fitted with self-closure devices where service users choose to have them open. Timescale for action 01/12/05 2 3 OP9 OP36 13(2) 18(2) 01/12/05 01/12/05 4 OP38 23 01/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Bullsmoor Lodge DS0000010662.V249308.R01.S.doc Version 5.0 Page 17 No. Refer to Standard Good Practice Recommendations Bullsmoor Lodge DS0000010662.V249308.R01.S.doc Version 5.0 Page 18 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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