Inspection on 19/07/05 for Colton Lodges Nursing Home

This inspection was carried out on 19th July 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

Colton Lodges Nursing Home 02/05/09

Colton Lodges Nursing Home 04/06/08

Colton Lodges Nursing Home 11/12/07

Colton Lodges Nursing Home 11/01/07

Colton Lodges Nursing Home 25/01/06

Colton Lodges Nursing Home 07/12/04

Colton Lodges Nursing Home 20/07/04

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

CARE HOMES FOR OLDER PEOPLE Colton Lodges 2 Northwood Gardens Leeds Yorkshire LS15 9HH Lead Inspector Gillian Sangster Announced 19 July 2005 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. Colton Lodges CS0000001332.V186541.R01.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Colton Lodge Address 2 Northwood Gardens Leeds LS15 9HH 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) 0113 2645288 0113 2326676 Bupa Care Homes Mrs Christine Brown Care home with nursing 120 Category(ies) of Old age (90) Dementia - over 65 (48) Mental registration, with number Disorder -over 65 (30) Physical disability (3) of places Colton Lodges CS0000001332.V186541.R01.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Garforth, Elmet and Whitkirk Houses - Old age (30 beds each house) Newsam House - Dementia and Mental Disorder over 65 years of age (30 beds) Whitkirk House - Physical disability age 21 , who are three named service users with chronic brain injury Specific dementia (age over 65) service users as identified in Bupa Care Homes letter dated 28 October 2003 Garforth House 7 places, Whitkirk 6 places and Elmet 5 places) Date of last inspection 6/12/04 Brief Description of the Service: Colton Lodges is in a residential area of Colton, close to local amenities and public transport routes. There is a car park to the front of the home and gardens are accessible to residents. The home is registered as a care home with nursing for 120 older people. Three places are registered for residents with a physical disability who are under pensionable age. Colton Lodges is purpose built comprising of four bungalows– Newsam, Garforth, Whitkirk and Elmet, each accommodating 30 people. Newsam provides nursing care for older people with dementia. Each bungalow provides 30 single en suite rooms, a communal lounge and dining area and three communal bathrooms. There is level access throughout the bungalows. Kitchen and laundry facilities are located centrally, although each unit has its own kitchenette for making drinks and light snacks. Colton Lodges CS0000001332.V186541.R01.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was carried out by two inspectors between 10am and 5.30pm. Time was spent talking to residents, staff and observing practice on three houses – Newsam, Elmet and Garforth. We also looked at records including duty rotas, residents’ care records, accident reports, recruitment records and staff training records. Some bedrooms and other areas were checked in Elmet and Garforth. The majority of the requirements from the last inspection have been addressed. Requirements and recommendations from this inspection are included at the end of the report. What the service does well: What has improved since the last inspection? Trips and outings for residents are now taking place on a regular basis. Cleanliness on Newsam and Elmet has improved. All staff are now receiving supervision. Colton Lodges CS0000001332.V186541.R01.doc Version 1.30 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Colton Lodges CS0000001332.V186541.R01.doc Version 1.30 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 Colton Lodges CS0000001332.V186541.R01.doc Version 1.30 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, 5 and 6. Good information is available about the home. Residents and their families are given an opportunity to look round before deciding whether to move in. The home does not provide intermediate care. EVIDENCE: All residents are assessed before admission to the home to make sure that their needs can be met. Pre-admission assessments provided detailed information about the individual’s needs. One relative described how staff had come out to assess her mother at home before she was admitted. Residents said that either they or their relatives had come to look round the home before moving in. Brochures and other information about the home, including the last inspection report, are freely available in the main entrance. The home does not provide intermediate care. However the majority of the beds are contracted to Leeds City Council. Colton Lodges CS0000001332.V186541.R01.doc Version 1.30 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, 10 and 11. Care planning is good apart from Garforth House where records need to be fully completed and updated. Health care needs are met. Residents are treated with respect and their privacy maintained. Staff require further training to make sure that terminal care and arrangements after death are discussed with residents and their family. EVIDENCE: Two residents’ care records were looked at in each of the three houses – Newsam, Elmet and Garforth. On Newsam and Elmet the care planning addressed the individual needs of the residents. Monthly evaluation takes place ensuring that changing needs are identified and appropriate action taken. Care planning was well documented and up to date. Recognised assessment tools are in use and risk assessments were in place. On Garforth the care plan for a recently admitted resident was not fully completed. Pre-admission information and daily records were detailed showing complex health and personal care needs. But this information had not been included in the care plan. Care records for another resident who has lived at the home for some years also needed attention. Many sections of the care plan needed rewriting as the person’s needs had clearly changed. Colton Lodges CS0000001332.V186541.R01.doc Version 1.30 Page 10 The records on Elmet and Garforth showed no evidence of resident or relative involvement in the care plans although the house managers said that planning was discussed with relatives. Arrangements are in place for residents to access health care services as required. The home provides a range of pressure relieving equipment including specialist mattresses and cushions. Wound care records seen for one resident were patchy and did not provide sufficient clinical detail to show whether the wound was healing or deteriorating. Feedback from relatives visiting Newsam and Garforth was very positive about the quality of the care provided. Residents on Garforth said that they were well cared for and praised the staff for their kindness describing them as “very good” and “caring”. Residents said that staff respected privacy and this was also confirmed in discussions with staff. They were able to give examples of how dignity and respect was promoted. One resident raised specific concerns relating to their care and these were passed on the manager for further investigation. Resident’s wishes and preferences regarding terminal care and arrangements after death had not been recorded in the care plan. The manager said that she knew that some staff found it difficult to discuss this subject with residents and relatives. There has already been some training for staff on dealing with death and dying and further training will now be provided. This should also include guidance for staff regarding the home’s policy and procedure on resuscitation. In one resident’s records there was a “do not resuscitate” order, which was a directive from the family. There was no evidence to show that this had been discussed and agreed with the resident or any of the health care professionals involved in the resident’s care. Colton Lodges CS0000001332.V186541.R01.doc Version 1.30 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 and 15 A planned programme of activities is provided for residents including trips out. Residents enjoy the food and are given a good choice of meals throughout the day. EVIDENCE: The home employs two hobby therapists who organise activities and outings for residents. Discussions were held with one of these staff who was very enthusiastic about her role. She said that she meets with all new residents and finds out about their interests and hobbies. She then tries to incorporate these interests into the monthly activity plan. There are usually trips out every Wednesday afternoon and a day out in Bridlington is being planned. Outside entertainers are brought in and a Summer Fayre is taking place at the end of July. The hobby therapist said that she and her colleague try to divide their time equally between all the houses but said that it was difficult to meet everyone’s needs in the hours that they work. It is recommended that an activity organiser is employed specifically for Newsam house to meet the specialist needs of the residents with dementia. This would also give the current hobby therapists more time to concentrate on the other three houses. The menus showed that a good varied, nutritional diet was provided. An “additions” menu was also available and this gave extra choices for residents. Colton Lodges CS0000001332.V186541.R01.doc Version 1.30 Page 12 A cooked breakfast or cereals started the day. Both the main and evening meals had a choice of a hot or cold food. Dining tables were appropriately laid for the main meal and these rooms provide a very pleasant environment. Residents spoke well about the quality of the food. It was apparent that residents are helped to make choices. For example a number were aware of the meal due to be served and were looking forward to it. One resident showed the inspector a copy of the menu. This is provided each week. Staff were observed giving a full explanation to a resident before moving her to a different area. One resident said that he preferred to stay in bed until 9 am and then have his breakfast. This was included in his care plan. Meals are delivered from the central kitchen to each house in a heated trolley and served to the residents in the dining room or their own rooms. All crockery and cutlery is hand washed by staff in the small kitchens in each house. Staff advised that this is necessary as the dishwashers do not get things clean unless they are washed first. The manager advised that two new dishwashers have been ordered. In the house that provides care for residents with dementia a board gave details of the day and date. This is a simple but effective way of providing orientation for those with memory loss. Colton Lodges CS0000001332.V186541.R01.doc Version 1.30 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. Complaints are listened to and dealt with according to the home’s complaint procedure. Staff have received training in adult protection and there are comprehensive policies about abuse. However staff must be familiar with the procedures and confident in when and how they should be used. EVIDENCE: There is a detailed complaints procedure and a record is maintained of all complaints received including details of the investigation and the outcome. The home has received six complaints since the end of March 2005 and all these had been dealt with in accordance with the home’s complaint procedure. The registered manager was aware of her responsibilities in cases of abuse and she was due to attend an adult protection course in York. It was recommended that she attend a course in Leeds as some procedures may vary between authorities. During discussions staff also had a good understanding about the issues of elder abuse and confirmed that in house talks had been organised. The Newsam house manager confirmed that all staff have attended elder abuse training. BUPA provides detailed information about the different types of abuse and how these can be recognised. Yet one care record showed a resident was found with bruises to her hand and, although concerns had been expressed by relatives, there was no evidence to show that the cause of the bruising had been investigated. The manager agreed to investigate this incident. Colton Lodges CS0000001332.V186541.R01.doc Version 1.30 Page 14 House managers had some understanding of adult protection but need to have a thorough understanding of the procedures in the event of this happening. This could be achieved by displaying a flow chart in each office. This would identify the person’s responsibilities and also the steps each person should take. Colton Lodges CS0000001332.V186541.R01.doc Version 1.30 Page 15 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, 20, 24 and 26. The home provides comfortable accommodation that is well maintained. Residents’ rooms are personalised and comfortably furnished. The home is clean with no malodours. EVIDENCE: The houses have easy access to their own gardens. Newsam house has secure gardens for residents to access safely at will. These gardens are well kept and provide pleasant areas for residents to enjoy in good weather. Staff confirmed that residents are taken out into the grounds in order to enjoy the fresh air. Some bedrooms and facilities were inspected in Elmet and Garforth. Residents said that they liked their rooms and were comfortable. Many had personal possessions displayed such as photographs, ornaments and pictures. On Elmet a wheelchair was in a dirty condition and some lounge chairs had food spillage otherwise all areas were clean with no malodours. Colton Lodges CS0000001332.V186541.R01.doc Version 1.30 Page 16 Sluice rooms are separated from resident areas. These were clean with no malodour. The coating on the racks used to store bedpans and bottles had deteriorated and could not be adequately cleaned. These racks should be replaced. The manager said that there had been a shortage of housekeeping staff recently due to sickness and some staff leaving. The home is currently recruiting new housekeeping staff and interviews were planned for the week following this inspection. Colton Lodges CS0000001332.V186541.R01.doc Version 1.30 Page 17 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. Staffing levels are sufficient to meet service users’ needs apart from Garforth house where they must be reviewed. Recruitment procedures make sure that staff are suitable before they start work in the home. The home has a comprehensive training programme to make sure that staff receive the training and support they need to carry out their jobs. EVIDENCE: Duty rotas are maintained for all staff. As at the last inspection concerns about staffing levels on Garforth were raised by a relative and staff. Staff said that due to the high dependency levels they were not able to help some residents get up till nearly lunchtime. Staff said that they felt they were rushing residents in order to get all the work done rather than being able to give them the time and support they needed to do some things themselves. Discussions were held with the manager who said that staffing levels had been reviewed following the last inspection visit and were found to be satisfactory. It was agreed that a further review of the working practices on this house would be reviewed to ensure that the needs of the residents are being met appropriately. The home has a training officer who makes sure that staff receive the training necessary for providing care to older people. Records show that all staff have completed induction and foundation training. All new staff complete a three day induction programme with the training officer. This was confirmed in discussions with staff. The training officer said that the programme can be adapted to meet the individual needs such as spending more time with some Colton Lodges CS0000001332.V186541.R01.doc Version 1.30 Page 18 overseas staff to make sure that communication and written skills are fully understood. Supervision of staff is also ongoing. The training records showed the courses attended by staff. Staff employed for some years confirmed that they had received training in the last six months in moving and handling, fire safety, food hygiene, COSSH, peg feeding, risk assessment and death and dying. One adaptation nurse also confirmed additional training undertaken and spoke well about the support received from her mentor. The house manager on Newsam has completed an introduction to Quality Dementia Care and will be completing an NVQ level three in Dementia. Staff on all the houses are completing “Understanding Dementia Care” training. The manager anticipates that all of the staff will have completed this training by the end of August 2005. Recruitment practices were good. Staff files were well kept with evidence of CRB checks and references obtained before employment began. Job description and terms and conditions were available. A staff handbook was also issued. Colton Lodges CS0000001332.V186541.R01.doc Version 1.30 Page 19 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) 31, 33 and 38. The home is well organised and the manager provides effective leadership. Residents and relatives are encouraged to participate in all aspects of the home and there are good systems of communication in place. Health and safety of residents and staff is promoted and protected. EVIDENCE: A new registered manager has started since the last inspection. This person has extensive management experience and provides effective leadership. The organisation undertakes an annual satisfaction survey. The results of the 2005 survey were available. Residents and relatives meetings are held in all the houses. Relatives on Newsam said this was of great benefit in understanding the changes occurring due to dementia. Fire alarms were being tested on the day of inspection. Colton Lodges CS0000001332.V186541.R01.doc Version 1.30 Page 20 Accident forms were completed satisfactorily apart from recording the time the resident was last seen by staff before the accident occurred. Accident records showed that when there may have been head injuries observations were carried out. Training records show that all staff have received training in health and safety. Moving and handling techniques were a concern on Elmet as staff were using Kirton chairs to transport residents. Staff were observed using correct methods of moving and handling on Newsam. A possible reassessment of the techniques and equipment used for one resident was discussed with the registered manager. Colton Lodges CS0000001332.V186541.R01.doc Version 1.30 Page 21 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 3 x x x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 x x x 3 x 3 STAFFING Standard No Score 27 2 28 x 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 3 x 3 x x x x 3 Colton Lodges CS0000001332.V186541.R01.doc Version 1.30 Page 22 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard op7 Regulation 15 Requirement All residents on Garforth house must have an up-to-date care plan that shows how health, socail and personal care needs are met. Residents and/or their relatives must be consulted in the drawing up and review of the care plan. Wound care records must be kept up-to-date and provide clinical evidence to show the treatment and outcome. All senior staff should have a full understanding of the adult protection procedures and know when to use them. Staffing levels and working practices on Garforth house must be reviewed to ensure that residents needs are being met appropriately. Timescale for action 31/10/05 2. 3. op7 op8 15 13 31/10/05 31/10/05 4. op18 13 31/09/05 5. op27 18 31/08/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Colton Lodges CS0000001332.V186541.R01.doc Version 1.30 Page 23 1. 2. 3. 4. op11 op12 op26 op30 Residents individual preferences and wishes regarding terminal care and arrangements after death should be discussed and recorded. An activity organiser solely for Newsam house should be provided. The storage racks in the sluice room on Elmet and Newsam should be replaced. All staff should be informed of the homes policy on resuscitation and the procedure to follow if someone asks not to be resuscitated. Colton Lodges CS0000001332.V186541.R01.doc Version 1.30 Page 24 Commission for Social Care Inspection Aire House Town Street Rodley LS13 1HP 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 Colton Lodges CS0000001332.V186541.R01.doc Version 1.30 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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