Inspection on 25/01/06 for Colton Lodges Nursing Home

This inspection was carried out on 25th 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 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 19/07/05

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 Nursing Home 2 Northwood Gardens Leeds Yorkshire LS15 9HH Lead Inspector Hebrew Rawlins Unannounced Inspection 25th 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 Colton Lodges Nursing Home DS0000001332.V278566.R01.S.doc Version 5.1 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. Colton Lodges Nursing Home DS0000001332.V278566.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Colton Lodges Nursing Home Address 2 Northwood Gardens Leeds Yorkshire LS15 9HH 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) 0113 2645288 0113 2326676 www.bupa.com BUPA Care Homes (CFHCare) Limited Mrs Christine Mary Brown Care Home 120 Category(ies) of Dementia - over 65 years of age (48), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (30), Old age, not falling within any other category (90), Physical disability (4) Colton Lodges Nursing Home DS0000001332.V278566.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 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) The fourth PD place is specifically for the service user named in the variation application dated 27.6.05 19th July 2005 Date of last inspection 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 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 Nursing Home DS0000001332.V278566.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Over an inspection year from April until March, care homes have a minimum of two inspections a year; these may be announced or unannounced. The last inspection was announced and took place on the 19th July 2005. There have been no further visits until this unannounced inspection. This inspection was carried out between the hours of 10.00am and 5.00pm by two inspectors. The people who live in the home prefer the term resident therefore this is the term that will be used throughout this report. During the inspection, we looked at records, saw care staff carrying out their work, made a tour of some parts of the building and spoke with residents, staff, visitors, unit managers and the overall manager. Comment cards/questionnaires are left for residents, visitors and other professionals at each inspection. These provide an opportunity for people to share their views of the home with the Commission for Social Care Inspection (CSCI). We discuss any comments received with the manager, without revealing the identity of those completing them. Copies of previous inspection reports are available via the Internet at www.csci.org.uk. What the service does well: What has improved since the last inspection? Colton Lodges Nursing Home DS0000001332.V278566.R01.S.doc Version 5.1 Page 6 Resident’s wishes regarding terminal care and arrangements after death are discussed and recorded. Care planning on Garforth has improved so that resident’s needs are clearly identified and staff are clear what help and support is needed. Care staff, residents and relatives are encouraged be involved in the care planning process. Staffing levels and working practices on Garforth has been reviewed to make sure that the needs of the residents are being met appropriately. 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 Nursing Home DS0000001332.V278566.R01.S.doc Version 5.1 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 Colton Lodges Nursing Home DS0000001332.V278566.R01.S.doc Version 5.1 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 the following standard(s): 3,4,and 5. Pre-admission visits are offered and the makes sure the home can meet the needs of future residents. EVIDENCE: All residents are assessed by Unit Managers 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. Trial visits are encouraged, however mainly relatives visit the home. A resident and his family said that a social worker had given them a choice of three homes; they had chosen Colton Lodge because they had heard good reports about it and it was convenient for most of the family members. Colton Lodges Nursing Home DS0000001332.V278566.R01.S.doc Version 5.1 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 the following standard(s): 7,8,9 and 11. Some clarification is needed to guide staff on retention of current documentation for care plans. Night staff should write the night care plans. Records relating to medication sheets must be improved. EVIDENCE: The home is piloting new care plans Ability Assessment For Older People based on the Minimum Data Set (MDS) model of assessment. Where a need is identified a care plan sheet will be devised indicating the response required to meet the identified problem or issues. Staff confirmed that training had taken place on the new documentation but some clarification is needed to guide staff on retention of current documentation. Files looked at showed risk assessments of falls, permission to use restraint, dependency, waterlow, manual handling. Nutritional risk assessments are done for all residents at the time of admission. There is evidence available to show that relatives are fully aware of any changes in resident’s condition. Good information seen in progress records, however problems identified are not always carried forward to care planning process. End of life situations are Colton Lodges Nursing Home DS0000001332.V278566.R01.S.doc Version 5.1 Page 10 discussed and documented in care plans. The night care plans are written by day staff, it is recommended night staff write these. Pressure ulcers identified. Involvement with tissue viability evidenced wound mapped but grading by using Stirling Scale not undertaken by Garfield staff. The home uses the Nomad dosage system for medicines, provided by a local pharmacist. MAR Charts – Extra direction labels seen (leaves potential for mistakes to be made if label is stuck to wrong MAR chart. Mucodyne capsules (hand written) on MAR chart, not signed by nurse making entry and no amount of capsules documented. Oxygen cylinders were found standing unfixed/unsecured in treatment room. Colton Lodges Nursing Home DS0000001332.V278566.R01.S.doc Version 5.1 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 the following standard(s): 12 and 15. A range of activities is provided in the home. Meals and mealtimes are satisfactory. Residents enjoy the food served. EVIDENCE: Planned programme of activities (sing a long on day of visit prior to lunch) is offered. The home has 2-hobby therapist one of whom spends most of the time on the Garforth unit. Hobbies are recorded in residents care plans so that activities could be planned around them. Christmas parties were held on each unit with outside entertainers. The money raised from the home fund raising activities bought gifts for residents. Discussion took place with several residents about the meal in the home. Certain residents were aware of what the main meal of the day was. All residents were happy to state there was a choice for each meal and the food was well presented and well cooked. Meals are served from the main kitchen in hot trolleys and probed before being served. Menus are displayed on tables. The staff were pleasant and encouraging and assisted those people who needed feeding in an appropriate manner. Staff and most residents participated in verbal banter and the social atmosphere was good throughout the day. Visitors to the home said they were made welcome and were kept up to date with any changes in their relative’s wellbeing. Colton Lodges Nursing Home DS0000001332.V278566.R01.S.doc Version 5.1 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 home provides clear information on how to make a complaint about the service. It includes reference to the commission for Social Care Inspection if people want to take a complaint outside the home. All unit managers should be aware of the process of reporting suspected abuse and all staff must have adult protection training if they and residents are not to be at risk. EVIDENCE: The home has a policy for dealing with complaints. All complaints received had been dealt with in accordance with the home’s complaint procedure. Talking to staff, they are all clear on their responsibility about reporting any allegations of abuse. However some staff have not yet had adult protection training and one unit manager was not aware of the process of reporting suspected abuse. The manager has recently finish investigating a complaint and written back to the complainant of her findings. Colton Lodges Nursing Home DS0000001332.V278566.R01.S.doc Version 5.1 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): 19,20,23,24 and 26 Residents live in a generally clean, pleasantly furnished home. Each person has his or her own bedroom. A range of comfortable shared space is also available. EVIDENCE: Only some areas of the home were inspected at this visit. Communal areas are furnished and decorated to a good standard providing light and spacious accommodation. Externally there are well maintained accessible garden. Bedrooms seen were decorated and furnished to a good standard. Residents said that they were pleased with their rooms and were glad to have many of their own personal belongings with them. The carpet in one resident bedroom seen was split and shabby, the cot sides had no bumper pads which are health and safety issues. The door and window in another resident bedroom was visibly dirty on the inside. Those rooms were identified to the manager at the end of the inspection feedback. All other areas of the home were clean with no malodours. Colton Lodges Nursing Home DS0000001332.V278566.R01.S.doc Version 5.1 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): 30. There is a stable staff team at the home, who know the residents very well. Staff maintain their competence through ongoing training and development programmes. EVIDENCE: Several staff were spoken with during the inspection. One member of staff has been employed 3 months stated she completed the induction training. A key worker for three residents was fully aware of their needs. She said she liked working at the home and had completed manual handling and fire safety training. She was aware of protection of vulnerable adult (POVA). She has had supervision whilst on induction. Another carer employed for over five years is doing NVQ level 3 training and is due to finish in 3 months time. She is starting First Aid course and is key worker for three residents, is aware of their needs, is up to date with mandatory training. Aware of COSH and POVA, has completed institute of environmental health officers basic food hygiene certificate. Has had Abuse awareness training and would report any incidences. She said she had a good unit manager, can go to him and discuss problems as they arise and has formal supervision. Colton Lodges Nursing Home DS0000001332.V278566.R01.S.doc Version 5.1 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): 31,32 and 36. The manager is highly respected, hardworking and committed to providing a quality service. EVIDENCE: There was evidence the home is well managed. The care plan documentation, activities provided and staff supervision shows this. Positive comments from residents and visitors saying they liked the home and the manager and staff were very kind to them. The home was recommended to them because of the manager. One relative stated she is confident her husband would be well cared for if she was unable to visit. The home was recommended to her and she waited until a place became available. Colton Lodges Nursing Home DS0000001332.V278566.R01.S.doc Version 5.1 Page 16 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 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 2 3 x x 3 x x 3 STAFFING Standard No Score 27 X 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 3 X x Colton Lodges Nursing Home DS0000001332.V278566.R01.S.doc Version 5.1 Page 17 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard OP7 OP9 Regulation 15 13 Requirement Timescale for action 01/04/06 3. OP18 13 Problems identified must always be carried forward to care planning process. Tissue viability evidenced wound 01/04/06 is mapped but staff should undertake grading by using Stirling Scale. Records relating to medication sheets must be improved and oxygen cylinders should be fixed/secured in treatment room. All unit managers should be 01/04/06 aware of the process of reporting suspected abuse and all staff must have adult protection training if they and residents are not to be at risk.(raised at last inspection) The carpet in one resident bedroom seen was split and shabby, the cot sides had no bumper pads which are health and safety issues. The door and window in another resident bedroom was visibly dirty on the inside. 01/04/06 4. OP19 23 Colton Lodges Nursing Home DS0000001332.V278566.R01.S.doc Version 5.1 Page 18 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. 2. Refer to Standard OP7 OP12 Good Practice Recommendations Night staff should write the night care plans. An activity organiser solely for Newsam house should be provided. Colton Lodges Nursing Home DS0000001332.V278566.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Aire House Town Street Rodley Leeds 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 Nursing Home DS0000001332.V278566.R01.S.doc Version 5.1 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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