Inspection on 16/01/06 for Catherine Lodge

This inspection was carried out on 16th January 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 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 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 Unannounced Inspection 16th January 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 Catherine Lodge DS0000010399.V269991.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. Catherine Lodge DS0000010399.V269991.R01.S.doc Version 5.0 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 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.V269991.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th August 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 homes stated aims include that residents achieve a quality of life, which is individualised, sensitive to their needs and of a high standard. Catherine Lodge DS0000010399.V269991.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on Monday 16th January 2006 and lasted four hours. Eight residents and four staff were interviewed and care records were examined. A partial tour of the building took place. The registered manager and staff were open and helpful throughout the inspection. One service user told the inspector “I don’t think you will find anything wrong here”. Other comments received by service users were also overwhelmingly positive regarding the manager and staff at 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. Catherine Lodge DS0000010399.V269991.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 Catherine Lodge DS0000010399.V269991.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): 3 All service users have a good assessment carried out before they move into the home for a trial period. 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. There was a record of meetings following trail periods. Catherine Lodge DS0000010399.V269991.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): 7, 8 and 9 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. 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 DS0000010399.V269991.R01.S.doc Version 5.0 Page 9 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. Training certificates were seen for all staff who administer medication. Catherine Lodge DS0000010399.V269991.R01.S.doc Version 5.0 Page 10 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 and 15 Service users’ social, cultural and recreational needs are well met by the home. Service 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. An activities worker was employed in May of this year and one service user commented that her input has been “marvellous”. One service user is also undertaking an IT computer course outside of the home. 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 inspector noted that individual parts of each meal were not being pureed separately. A requirement has been made relating to this issue in the relevant section of this report. Hot drinks and biscuits were Catherine Lodge DS0000010399.V269991.R01.S.doc Version 5.0 Page 11 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 and these likes and dislikes were known by the chef. Catherine Lodge DS0000010399.V269991.R01.S.doc Version 5.0 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 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. No complaints had been received since the last inspection. 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 DS0000010399.V269991.R01.S.doc Version 5.0 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 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. Catherine Lodge DS0000010399.V269991.R01.S.doc Version 5.0 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 and 29 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 “ First class” another service user told the inspector that “You will not get better staff anywhere”. A requirement was issued at the last inspection that up-to-date references must be obtained for all staff working at the home. The inspector 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. The requirement has now been complied with. Catherine Lodge DS0000010399.V269991.R01.S.doc Version 5.0 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, 33, 35 and 38 The home is well run by a committed and professional manager. Service users have a say in how the home is run. Service users’ financial interests are safeguarded by clear and accurate accounting systems. There are good systems in place to monitor health and safety compliance at the home. EVIDENCE: The registered manager is a qualified nurse and is currently undertaking the registered managers award. Both staff and service users that the inspector spoke with were very positive regarding the manager and it was clear that everyone at the home benefits from the her hands on approach and commitment to improving the service. A quality audit is carried out twice a year and satisfactory records were seen including comments from service users and their representatives. The manager carries out a monthly report where service users comments are received. The Catherine Lodge DS0000010399.V269991.R01.S.doc Version 5.0 Page 16 service users have a meeting together every month and it was clear from these meeting minutes that any suggestions or concerns are acted upon. Service users that the inspector spoke with confirmed that they felt they had a say in how the home was run. 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. Records were examined in relation to these invoices and clear and accurate audit trails were seen. Two requirements were issued at the last inspection that night staff undertake fire drills every three months and that all accidents are reported to the CSCI. Both these requirements have now been complied with. 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 (10/05) 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 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. Catherine Lodge DS0000010399.V269991.R01.S.doc Version 5.0 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 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X X STAFFING Standard No Score 27 3 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Catherine Lodge DS0000010399.V269991.R01.S.doc Version 5.0 Page 18 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. 1. Standard OP15 Regulation 16(2)(i) Requirement The registered manager must ensure that individual parts of each meal are pureed separately for those service users with swallowing problems. Timescale for action 01/02/06 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 Catherine Lodge DS0000010399.V269991.R01.S.doc Version 5.0 Page 19 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. Extracts may not be used or reproduced without the express permission of CSCI Catherine Lodge DS0000010399.V269991.R01.S.doc Version 5.0 Page 20 - 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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