Inspection on 10/08/05 for Catherine Lodge

This inspection was carried out on 10th August 2005.

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 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 01/10/07

Catherine Lodge 11/09/06

Catherine Lodge 16/01/06

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 36042 Woodside Park Road North Finchley London N12 8RP Lead Inspector David Hastings Unannounced 10th August 2005 @ 09.30 am 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. Catherine Lodge 20050810 Catherine Lodge X00015 UN Stage 4 S10399 V240478 G59.doc Version 1.40 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 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 Stimpson PC Care Home only 39 beds Category(ies) of OP Old Age registration, with number DE(E) Dementia over 65 of places Catherine Lodge 20050810 Catherine Lodge X00015 UN Stage 4 S10399 V240478 G59.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 28 February 2005 Brief Description of the Service: Catherine Lodge is a privately run residential home that is registered to provide a service for 39 elderly 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 home’s stated aims include that residents achieve a quality of life, which is individualised, sensitive to their needs and of a high standard. Catherine Lodge 20050810 Catherine Lodge X00015 UN Stage 4 S10399 V240478 G59.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on Wednesday 10th August 2005 and lasted six hours. Seven residents and four staff were interviewed and care records were examined. A partial tour of the building took place. Twelve comment cards were received from residents and sixteen from relatives and other visitors. These were all positive regarding the care provided by the manager and staff at the home. Residents’ comments included “I feel at home and safe here” and “all ok”. Relatives’ comments included “the staff appear to know my mother very well” and “my mother receives excellent care” and “the staff treat my mother with love, care and dignity”. The registered manager and staff were open and helpful throughout the inspection. What the service does well: What has improved since the last inspection? What they could do better: Three requirements have been issued as a result of this inspection. Staff files must contain all the information required including two up to date references. The CSCI must be notified of any accidents and incidents covered by Regulation 37 of the Care Homes Regulations 2001 and night staff must undertake fire drills every three months. The inspector is confident that the registered manager will comply with these requirements within the timescales given. Catherine Lodge 20050810 Catherine Lodge X00015 UN Stage 4 S10399 V240478 G59.doc Version 1.40 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. Catherine Lodge 20050810 Catherine Lodge X00015 UN Stage 4 S10399 V240478 G59.doc Version 1.40 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 Catherine Lodge 20050810 Catherine Lodge X00015 UN Stage 4 S10399 V240478 G59.doc Version 1.40 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) 3 and 4 (6 not applicable). All service users have a good assessment carried out before they move into the home for a trial period. The home is able to meet the needs of the service users living there. EVIDENCE: The inspector saw evidence from the service user files examined that full assessments had been undertaken, by people trained to do so, for service users prior to admission. New service users confirmed that they had visited the home before moving in and there was a record of meetings following trail periods. The inspector found that the home had the services of a number of health professionals whose advice was sought regularly. The registered manager has experience in the care of older people and is a trained nurse. Care plans focused on health, medical, physical, social and psychological needs with anticipated outcomes and actions required. Care practices observed during the inspection showed components of the care plans being put into practice. Service users that the inspector spoke with confirmed that the home was able to meet their needs. Catherine Lodge 20050810 Catherine Lodge X00015 UN Stage 4 S10399 V240478 G59.doc Version 1.40 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 standard(s) 7, 8, 9 and 10. Service users’ health, personal and social care needs are understood and met by the manager and staff at the home. Service users get the right medication prescribed at the correct times, given by appropriately trained staff. Service users are treated with respect and their privacy is maintained. EVIDENCE: The inspector examined six service user records. All service users’ records contained care plans, which identified the individual needs, matched them to corresponding services and detailed the objectives to be achieved. The care plans covered a wide range of health, personal and social care needs and were reviewed monthly and accompanied by risk assessments on manual handling/falls and diet. There was evidence that yearly reviews take place with the placing authority. All service users are registered with a GP and the home contracts with the GP to ensure weekly visits to the home for consultations. All service users have access to district nurses. A dentist, hygienist, optician and chiropodist, visit the home to examine and treat service users. Service users are referred to a geriatrician, community psychiatric nurse, and psycho geriatrician, as Catherine Lodge 20050810 Catherine Lodge X00015 UN Stage 4 S10399 V240478 G59.doc Version 1.40 Page 10 necessary. The home operates a continence management system, receives advice from the district nurses regarding pressure relief and there is a lot of emphasis on service users drinking plenty of water. All service users are assessed for the risk of developing pressure sores and records of these assessments are maintained in service user plans. The records in relation to the receipt, administration and disposal of medication were examined and were accurate and detailed. The medicine trolley is stored in the dining room and the temperature of the area is monitored and recorded. The fridge temperature is also recorded daily. The home has recently started a new dosage system and staff said they felt it was easy to understand and use. Staff are expected to knock at bedroom, toilet and bathroom doors and were observed doing this. Frequent toileting programmes were carried out discreetly and sensitively. There is a pay ‘phone but the home has found that service users find using one of the home’s two mobile ‘phones more convenient; eight service users have their own ‘phone installed in their rooms. Service users were observed to be appropriately dressed and clothes have individual nametapes. Shared rooms were provided with screens. Examinations are carried out in the service user’s room or nurse’s room. Service users confirmed to the inspector that staff are respectful and always knock on their bedroom door before entering. Catherine Lodge 20050810 Catherine Lodge X00015 UN Stage 4 S10399 V240478 G59.doc Version 1.40 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 standard(s) 12, 13, 14 and 15. Service Visitors Service Service users’ social, cultural and recreational needs are well met by the home. to the home are welcomed and can visit at any reasonable time. users are able to exercise choice and control over their lives. users receive a wholesome and balanced diet in pleasant surroundings. EVIDENCE: As found at the previous inspections, there was evidence that service users are able to exercise choice in their daily lives. There is a programme of twice daily activities (including weekends), which are based on service users’ preferences and discussed at their meetings; they include: bingo, reminiscence, musical entertainment, a quartet of bridge players, scrabble. Service users informed the inspector that they were kept well occupied at the home. Service uses are supported in attending religious functions as they wish. An activities worker was employed in May of this year and a number of the service users were taking part in a quiz session during the inspection. Records were seen regarding the times individual service users wanted to go to bed. Service users that the inspector spoke with confirmed that visitors were always made welcome and could visit at any reasonable time and records examined confirmed this. Catherine Lodge 20050810 Catherine Lodge X00015 UN Stage 4 S10399 V240478 G59.doc Version 1.40 Page 12 The registered manager said that access to their records would be facilitated on request. Service users bring personal possessions with them and evidence of this was seen in their bedrooms. The financial affairs of most of service users are handled by themselves or their relatives. The registered manager informed the inspector that she does not retain any money on behalf of service users but invoices relatives if required. Breakfast is based on individual choices. A three-week rolling menu for lunch is based on service users known preferences with a range of alternatives; supper consists of soup, a range of cooked choices, salads and dessert. The meals were favourably commented on by service users and they confirmed that they were always offered a choice of menu. Staff were observed assisting service users sensitively. Some service users need modified diets for diabetes or had their meals liquidised. The cook showed awareness of these individual’s needs. Hot drinks and biscuits were served morning and afternoon and a late supper of sandwiches, or biscuits are served for those who wish. The inspector noted that service users were being encouraged to drink healthy quantities of water throughout the day. The inspector was invited to lunch with the service users. This was sociable and unhurried and the meal was appetising. Service users likes and dislikes with regard to food were recorded in their care plans. Catherine Lodge 20050810 Catherine Lodge X00015 UN Stage 4 S10399 V240478 G59.doc Version 1.40 Page 13 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) 16 and 18. The manager of the home makes sure that all complaints are taken seriously and are resolved properly. Service users are protected from abuse by a clear and detailed Adult Protection procedure. 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 service user is logged, together with the action taken and the outcome. This demonstrates a commitment to listening and responding to service users’ wishes. The record of complaints was examined. One compliant had been received since the last inspection. This complaint had been dealt with appropriately by the manager. Service users commented that if they had a complaint they would speak to the manager and that she listened to all their concerns. Records examined of service users’ meetings confirmed this. The home has an Adult Protection procedure, which details the types of abuse to which older people may be vulnerable. The procedure is clear about the action staff must take if abuse is suspected. The registered manager was aware of her responsibility to report allegations of abuse to the appropriate authorities, including the local Adult Protection Unit and the CSCI. Catherine Lodge 20050810 Catherine Lodge X00015 UN Stage 4 S10399 V240478 G59.doc Version 1.40 Page 14 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 and 26. Catherine Lodge has a homely atmosphere and is clean, safe, well-maintained and decorated to a high standard. EVIDENCE: 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 service users in wheelchairs. The lounges and dining rooms, together with the hall, landings, staircases and corridors are decorated to a good standard. The bedrooms are pleasant and comfortably furnished, the bed linen and curtains were clean and fresh. A regular maintenance check is made and the property is well maintained. The registered manager was able to provide written evidence of audits made of all rooms which clearly identified repair and refurbishment programmes. Service users told the inspector that the standard of cleanliness at the home was very good. Continence management systems are in place and the home was free from offensive odours. The home has policies on infection control and dealing with spillages; latex gloves and protective aprons were seen to be available. All staff were caring alcohol gels. Laundry and clinical waste were Catherine Lodge 20050810 Catherine Lodge X00015 UN Stage 4 S10399 V240478 G59.doc Version 1.40 Page 15 kept separate from the kitchen and food storage areas. The laundry is adequately equipped. The home has no separate sluicing facility; waste is disposed of through the ‘yellow bag’ system. The manager informed the inspector that staff would be undertaking a distance learning course in infection control shortly. Catherine Lodge 20050810 Catherine Lodge X00015 UN Stage 4 S10399 V240478 G59.doc Version 1.40 Page 16 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, 29 and 30 There are sufficient numbers of suitably trained staff on duty to meet the needs of service users. The home has satisfactory recruitment procedures. EVIDENCE: The rota indicates that the numbers of staff provided complies with the “no regression” policy for staffing levels, set out by the Department of Health in relation to existing care homes therefore this standard is met. 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. The staffing establishment consists of the registered manager, two deputy managers (currently both deputy posts are vacant), two senior care staff, thirteen care staff (including night staff), a cook and a chef and two domestic staff. Service users commented that the staff were “absolutely fabulous”. Staffing files were examined. Most contained all the information required by this standard. However two staff who have been employed from overseas did not have up to date references in their file. A requirement has been made relating to this in the relevant section of this report. Satisfactory CRB disclosures were seen in all files examined. Training records were examined. Staff have recently undertaken dementia training. This was a requirement from the last inspection that has now been complied with. The manager informed the inspector that further dementia training has been planned. Catherine Lodge 20050810 Catherine Lodge X00015 UN Stage 4 S10399 V240478 G59.doc Version 1.40 Page 17 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) 36 and 38 Staff are appropriately supervised. There are good systems in place to monitor health and safety compliance at the home. EVIDENCE: A requirement was issued at the last inspection that all staff must receive one to one supervision. Records examined indicated that this is now taking place and the requirement has been met. The home recently had a fire and service users had to be evacuated. No one was hurt and one service user informed the inspector that the staff were very calm and professional throughout the whole evacuation. As a result of the fire the home was inspected by the health and safety unit at Barnet and by the fire officer. As a result of the fire officer’s inspection a number of requirements were issued and the manager has now complied with these. Fire procedures were examined at this inspection. These were generally satisfactory however a Catherine Lodge 20050810 Catherine Lodge X00015 UN Stage 4 S10399 V240478 G59.doc Version 1.40 Page 18 requirement has been issued that night staff undertake fire drills every three months. The home has a range of health & safety policies, including manual handling, fire safety, first aid, food hygiene and infection control. Risk assessments relating to safety within the home were examined, maintenance checks had been made on the home and follow up work completed. Test certificates for gas (02/05), electrical installation (10/04), electrical appliances (10/04) 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 inspected by the local Environmental Health department on 17/02/04. The registered manager was able to explain to the inspector how the frequency of falls was being monitored at the home and how this monitoring contributed to individual risk assessments. A number of service users have been referred to the “falls clinic”. A satisfactory record of accidents was examined however these accidents were not being reported to the CSCI as required by Regulation 37 of the Care Homes Regulations 2001. A requirement has been issued in this report relating to this. Catherine Lodge 20050810 Catherine Lodge X00015 UN Stage 4 S10399 V240478 G59.doc Version 1.40 Page 19 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 x x 3 3 x x 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x x 3 x 2 Catherine Lodge 20050810 Catherine Lodge X00015 UN Stage 4 S10399 V240478 G59.doc Version 1.40 Page 20 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 29 Regulation 19 Requirement The registered manager must ensure that all staff files contain the information required by Regulation 19 including two written references. The registered manager must ensure that all night staff undertake fire drills every three months. The registered manager must ensure that all accidents and incidents are reported to the CSCI as outlined in Regulation 37 of the Care Homes Regulations 2001. Timescale for action 01/10/05 2. 38 23(4)(e) 01/09/05 3. 38 37 01/09/05 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 Good Practice Recommendations Catherine Lodge 20050810 Catherine Lodge X00015 UN Stage 4 S10399 V240478 G59.doc Version 1.40 Page 21 Commission for Social Care Inspection 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. Extracts may not be used or reproduced without the express permission of CSCI Catherine Lodge 20050810 Catherine Lodge X00015 UN Stage 4 S10399 V240478 G59.doc Version 1.40 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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