Inspection on 01/10/07 for Catherine Lodge

This inspection was carried out on 1st October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Catherine Lodge 11/09/06

Catherine Lodge 16/01/06

Catherine Lodge 10/08/05

Catherine Lodge 28/02/05

Catherine Lodge 23/08/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Catherine Lodge 36-42 Woodside Park Road North Finchley London N12 8RP Lead Inspector Mr David Hastings Key Unannounced Inspection 10:00 1st October 2007 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 Catherine Lodge DS0000010399.V343066.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. Catherine Lodge DS0000010399.V343066.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Catherine Lodge Address 36-42 Woodside Park Road North Finchley London N12 8RP 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) 020 8446 4292 020 8446 9456 Mrs Noreen Maria Christina Stimpson Mrs Noreen Maria Christina Stimpson Care Home 39 Category(ies) of Dementia - over 65 years of age (39), Old age, registration, with number not falling within any other category (39) of places Catherine Lodge DS0000010399.V343066.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th September 2006 Brief Description of the Service: Catherine Lodge is a privately run residential home that is registered to provide a service for 39 older people, some of whom may have dementia. It is owned and managed by Mrs Noreen Stimpson. The care home was originally four houses, which have been converted into a single home. Bedrooms are provided on three floors; there is a lounge interconnecting with two dining rooms at one end of the building and a separate quiet lounge at the other end. All the floors are accessible via a shaft lift; there is also a stair lift on one of the staircases. There is a large well-tended garden with a patio accessible through French windows. Catherine Lodge is situated just off the High Road in North Finchley, close to all the amenities: shops, churches, surgery and is within a few minutes walk of transport services. The homes stated aims include that residents achieve a quality of life, which is individualised, sensitive to their needs and of a high standard. The current scale of charges range from £440 to £600 per week. A copy of this report is available on the CSCI website or/and from the home. Catherine Lodge DS0000010399.V343066.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place on 1st October 2007 and lasted six hours. The registered manager, who was very open and helpful, assisted me throughout the inspection. I spoke with six staff, one visitor and twelve residents of the home. I inspected the building and examined various care records as well as a number of policies and procedures. All of the residents I spoke with said they were very happy with the care and support they received. One resident told me, “I’m very happy here”. What the service does well: What has improved since the last inspection? What they could do better: One recommendation has been issued that the staff review individual care plans with residents so they can have a say in how well they feel their care is being delivered. Catherine Lodge DS0000010399.V343066.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Catherine Lodge DS0000010399.V343066.R01.S.doc Version 5.2 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 Catherine Lodge DS0000010399.V343066.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 (6 not applicable) People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home carries out a comprehensive assessment of individual’s needs so that they know that the home is suitable for them before they decide to move in on a trial basis. EVIDENCE: I looked at the “Service User Guide”. This gives people information about the home and services and facilities available. The guide was detailed and included a clear statement that people from different backgrounds and cultures were welcome and that any discrimination would not be tolerated at the home. This ensures that Catherine Lodge has an inclusive approach to the care of everyone at the home. I examined assessments of people who have recently moved into the home. These assessments were detailed and covered all the requirements of Standard 3.3 of the National Minimum Standards for Older People. People confirmed that either themselves or their relatives had visited the home prior to moving in on Catherine Lodge DS0000010399.V343066.R01.S.doc Version 5.2 Page 9 a trial basis. Residents I spoke to said that the staff knew them well and understood their needs. It was clear from discussion that the manager understood the importance of making sure the home could properly support the person before a decision to move in was made. There was evidence that people moving into the home have a review of their placement after four to six weeks to see if they are happy at the home and whether they decide to move in on a permanent basis. Catherine Lodge DS0000010399.V343066.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care plans clearly set out residents’ health, personal and social care needs so that staff know how best to support everyone at the home. Residents have good access to health care professionals and they are treated with respect. Residents get the medication they require, at the right times and by appropriately trained staff. EVIDENCE: Five care plans were examined. These plans were detailed and set out the plan of care for each individual for staff to follow. The plans set out the health, personal and social needs of residents. Risk assessments had been completed and were being reviewed so that the staff were aware of any potential issues that could affect the safety of the resident. Staff I interviewed had a good understanding of the needs of the people in their care. Although plans were being reviewed and updated regularly residents did not appear to be involved in the review of their own plans. A recommendation has been issued that residents views about the care provided to them are sought and recorded Catherine Lodge DS0000010399.V343066.R01.S.doc Version 5.2 Page 11 when care plans are reviewed. This will ensure that people have a say in how their care is provided. There were records on the residents’ files inspected of a range of health care checks by external health professionals. These included opticians, chiropodists and dentists. There was evidence of regular input from doctors including evidence of their attendance at the home. Residents are referred to a geriatrician, community psychiatric nurse, and psycho geriatrician, as necessary and the home operates a continence management system. Residents told me that their health care needs were being met by the home. The district nurses are treating two people at the home for pressure sores and pressure relieving equipment was being used for people who have been assessed as being at risk from developing pressure sores. Satisfactory records were examined in relation to the receipt, administration and disposal of medication. Medication was being stored appropriately and the temperature of the medication storage area was being monitored and recorded. Only those staff who have completed the medication training are permitted to administer medication. Throughout the inspection I saw examples of staff treating people with respect and upholding residents’ privacy. For example staff were seen to be knocking on people’s doors before going in. People I spoke with confirmed that they were treated with dignity and staff upheld their need for privacy. Staff I interviewed were able to give practical examples of how they uphold peoples’ privacy. Catherine Lodge DS0000010399.V343066.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents can choose from a range of activities at the home and are kept suitably occupied and engaged. Visitors to the home are made to feel welcome and can visit at any reasonable time. Residents are helped to exercise choice and control over their lives. The food provided is of good quality and mealtimes are relaxed and enjoyable. EVIDENCE: There is a programme of twice daily activities (including weekends), which are based on peoples’ preferences and discussed at their meetings; they include: bingo, reminiscence, musical entertainment, quizzes, dominoes and scrabble. Residents told me that they were kept well occupied at the home. One person told me, “I never get bored”. The home employs a full time activities coordinator and staff carry out activities with residents as well. On the day of the inspection staff were carrying out a quiz session and some staff were reading newspapers with residents and discussing current affairs. The atmosphere was lively and inclusive. There was evidence that residents go out of the home and a befriending service has been arranged for a resident who has little contact with their family. There was evidence from care plans that the Catherine Lodge DS0000010399.V343066.R01.S.doc Version 5.2 Page 13 religious and spiritual needs of residents are known by staff and that residents can follow their spiritual path I they wish to. The record of visitors indicated that residents could have visitors at any reasonable time. The visitor I spoke with said they were always made welcome and offered tea and biscuits when they visited. Residents I spoke with confirmed that visitors were welcomed. Residents confirmed that they were able to have choice and control over their lives at the home. Residents told me they could do what they liked and were not “bossed about” at all. One person told me, “I have a say in what I want to do”. Another resident said, “I can do what I like”. Staff I interviewed were able to give examples of how they ensure people are able to exercise choice and control within their daily routines. The kitchen was inspected. The kitchen was clean and there was a good selection of fresh food. Fridge and freezer temperatures were being monitored and recorded. People I spoke with were positive about the food provided by the home and confirmed that a choice of menu was always available. One resident told me that the food was “Terrific”. Lunchtime was a relaxed and staff were providing discreet assistance when required. Catherine Lodge DS0000010399.V343066.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Complaints are taken seriously and responded to in a professional manner. Residents are protected from abuse by clear policies and procedures and by an appropriately trained staff team. EVIDENCE: The home has a complaints procedure that complies with the National Minimum Standards. It specifies how complaints can be made, a 28-day timescale for a response and gives the details of the CSCI. Every complaint, however small, received from a resident is logged, together with the action taken and the outcome. This demonstrates a commitment to listening and responding to peoples’ wishes. The record of complaints was examined. A small number of minor concerns had been received since the last inspection. Records indicated that the manager had addressed these concerns in a timely manner. People who use the service commented that if they had a complaint they would speak to the manager and that she listened to all their concerns. Records examined of residents’ meetings confirmed this. One resident said that she had made a complaint about the food and the manager had sorted it out immediately. Catherine Lodge DS0000010399.V343066.R01.S.doc Version 5.2 Page 15 Staff were able to describe to me how vulnerable people could be at risk of abuse in a residential care setting. All staff were clear of their responsibility to report any suspicions of abuse to the appropriate authorities. Residents that I spoke to said they felt safe and well supported at the home. Records indicated that staff have undertaken training in the protection of vulnerable people. Catherine Lodge DS0000010399.V343066.R01.S.doc Version 5.2 Page 16 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 and 26 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Catherine Lodge has a homely atmosphere and is clean, safe, well-maintained and decorated to a high standard. The control of infection is managed well by good policies and procedures. EVIDENCE: I toured the building with the manager and visited a number of residents’ rooms. The home is accessible with a shaft lift connecting all floors, but there are small flights of two/three steps, which could render some bedrooms unsuitable to be accessed by people using wheelchairs. The lounges and dining rooms, together with the hall, landings, staircases and corridors are decorated to a high standard. The bedrooms are pleasant and comfortably furnished, the bed linen and curtains were clean and fresh. There are a number of shared bedrooms, which have screens to protect peoples’ privacy. A regular maintenance check is made Catherine Lodge DS0000010399.V343066.R01.S.doc Version 5.2 Page 17 and the property is well maintained. The manager was able to provide written evidence of audits made of all rooms which clearly identified repair and refurbishment programmes. Residents and visitors I spoke with said the home was always clean and there were no offensive odours detected throughout the home. One resident said, “There’s no smell, ever ”. Staff have undertaken training in infection control. The laundry has the equipment required to ensure that all items can be disinfected as needed. The flooring in the laundry area has been replaced to ensure that it can be kept suitably clean. Catherine Lodge DS0000010399.V343066.R01.S.doc Version 5.2 Page 18 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 and 30 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. All the staff at the home work very hard to meet the needs of residents and are provided with good training opportunities to further enhance their knowledge and skills. Recruitment practices are sufficiently detailed in order to protect residents at the home. EVIDENCE: The current rota confirmed that there are six care staff on duty during the morning and five staff in the afternoon. At night there are two waking night staff and two staff sleeping-in. Residents I spoke with were very positive about the staff and the way they were supported at the home. One person told me the staff were, “Very obliging”. Other residents told me that the staff were kind and polite towards them. Records indicated that around 85 of the staff team have completed their NVQ level 2 or equivalent. The training plan for the staff was examined. It was good to see that dementia training is given a high priority and is included in the mandatory training plan. Staff were positive regarding the opportunities for training at the home. Records of staff training indicated that the majority of staff have completed the Catherine Lodge DS0000010399.V343066.R01.S.doc Version 5.2 Page 19 required training and a rolling training programme is in place to ensure that all staff undertake the training needed to carry out their roles effectively. I examined the records of three newly appointed staff at the home. All these records contained the information required by Regulation 18 of the Care Homes Regulations 2001 including two written up-to-date references and satisfactory CRB disclosures. This ensures that residents are protected from unsuitable care staff working in the home. Catherine Lodge DS0000010399.V343066.R01.S.doc Version 5.2 Page 20 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 and 38 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The manager of the home knows the residents very well and understands their needs. Residents have opportunities to have a say in how the home is run. Residents’ financial interests are being safeguarded. The health and safety of residents and staff are promoted and protected. EVIDENCE: The registered manager and owner of the home, Mrs Noreen Stimpson, is a qualified nurse and has over twenty five years experience of management. The manager is currently undertaking the registered managers’ award. Both staff and residents that I spoke with were very positive regarding the manager and it was clear that everyone at the home benefits from her hands on approach Catherine Lodge DS0000010399.V343066.R01.S.doc Version 5.2 Page 21 and commitment to improving the service. One staff member commented that the manager was, “Very encouraging” and that she, “Encourages teamwork”. Both residents and staff commented that the home was well run. A quality audit is carried out twice a year and satisfactory records were seen including comments from residents and their representatives. The results of these surveys are now published and made available to residents in the home as well as potential residents to the home. The manager carries out a monthly report where residents’ comments are received. The people who use the service have a meeting together every month and it was clear from these meeting minutes that any suggestions or concerns are acted upon. Residents that I spoke with confirmed that they felt they had a say in how the home was run. The financial affairs of residents are handled either by themselves or their relatives. The home sends out invoices to residents or their representatives on a regular basis. Records were examined in relation to these invoices and clear and accurate audit trails were seen. The home has a range of health & safety policies, including manual handling, fire safety, first aid, food hygiene and infection control. Maintenance checks had been made on the home and follow up work completed. Test certificates for gas, electrical installation, electrical appliances and fire were inspected. COSHH substances were kept in a locked cupboard and data analyses were available. The front entrance is video monitored and windows were fitted with restrictors. The kitchen was last inspected by the local Environmental Health department in January 2007. No major concerns were noted in the report. The registered manager was able to explain how the frequency of falls was being monitored at the home and how this monitoring contributed to individual risk assessments as well as referrals to the “falls clinic”. Satisfactory records were examined in relation to fire safety. Catherine Lodge DS0000010399.V343066.R01.S.doc Version 5.2 Page 22 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 4 4 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 3 X X 3 Catherine Lodge DS0000010399.V343066.R01.S.doc Version 5.2 Page 23 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 Refer to Standard OP7 Good Practice Recommendations The registered person should ensure that the views of residents are sought every time care plans are reviewed. Catherine Lodge DS0000010399.V343066.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Harrow Area Office 4th Floor, Aspect Gate 166 College Road Harrow London HA1 1BH 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 Catherine Lodge DS0000010399.V343066.R01.S.doc Version 5.2 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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