Inspection on 26/01/06 for Courtland Lodge

This inspection was carried out on 26th 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

Courtland Lodge 10/12/07

Courtland Lodge 20/12/06

Courtland Lodge 14/06/05

Courtland Lodge 28/02/05

Courtland Lodge 27/07/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Courtland Lodge Courtlands Drive Watford Hertfordshire WD1 3HR Lead Inspector Mrs Alison Butler Unannounced Inspection 26th 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 Courtland Lodge DS0000019325.V280582.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. Courtland Lodge DS0000019325.V280582.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Courtland Lodge Address Courtlands Drive Watford Hertfordshire WD1 3HR 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) 01923 681231 01923 689867 www.quantumcare.co.uk Quantum Care Limited Ms Hilary Woodhouse Care Home 60 Category(ies) of Dementia - over 65 years of age (60), Old age, registration, with number not falling within any other category (60), of places Physical disability over 65 years of age (60) Courtland Lodge DS0000019325.V280582.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th June 2005 Brief Description of the Service: Courtland Lodge is a purpose built two-storey building providing sixty residential places in four self contained units. Four of the bedrooms are used to provide respite care. All bedrooms are for single occupancy and each has an en-suite toilet and wash hand basin. Each of the units has a dining room, kitchenette and lounge. A day centre, the main kitchen, laundry, reception area, communal sun lounge and the administrator’s office is located centrally on the ground floor. The home has a landscaped garden and ample off road parking. It is located close to a parade of shops that offers a variety of retail outlets and a Post Office. There is a local bus service that provides easy access to the town centre. Courtland Lodge DS0000019325.V280582.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was the second required by legislation in the year. It was conducted by two inspectors and took a total 8 hours. Discussions were held with residents, staff, visitors and the senior management team of the home. Staff were observed carrying out their duties and interacting with the residents. A tour of the premises took place; documentation was examined including care plans, medication records, accident and incident records, and complaints. There were 56 residents were in residence on the day of this inspection. Where standards remain the same, the text has been carried forward from the previous report. What the service does well: What has improved since the last inspection? What they could do better: Areas for redecoration must be attended to bring them up to an acceptable standard. Courtland Lodge DS0000019325.V280582.R01.S.doc Version 5.1 Page 6 The laundry room is need of major redecoration to bring it up to an acceptable standard and ensure that all equipment is in full working order. Internal and external medication should be stored separately and medication should be stored in line with the manufacturers instructions to prevent deteriation. The proprietor must ensure that their visits to the home are placed into a written report detailing the conduct of the home and forwarded to the Commission For Social Care Inspection every month. The last report received by the commission was in October 2005 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. Courtland Lodge DS0000019325.V280582.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 Courtland Lodge DS0000019325.V280582.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): 1 Up to date information is available to prospective residents to ensure they are able to make an informed choice. EVIDENCE: An up dated copy of the Statement of Purpose and Service Users Guide has been received following the appointment of the new manager. Courtland Lodge DS0000019325.V280582.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, 10 The quality of the information is not always very detailed especially on the progress notes. Residents receive good quality care and their privacy and respect is upheld. Staff are experienced and knowledgeable to support the residents. EVIDENCE: Examination of care plans showed that the care required for residents was detailed. The progress notes showed gaps were no information had been recorded. Examples include information that had been recorded that an individual had got red & sore sacral area but no further observations were recorded. There was also a ten-week gap on the care plan track sheet which considering the frailty of the residents was deemed as unacceptable. There is discrepancy between the front sheet and the information on the personal history were one states “not practising C of E” although the other states “used to go to church weekly with husband”. Residents were complimentary about the care they received and staff knock before entering their bedrooms. Courtland Lodge DS0000019325.V280582.R01.S.doc Version 5.1 Page 10 A number of issues were identified with the medication. Lactulose should be stored in line with the manufacturers directions at below 20°C as the record of temperatures was in the region of 22.6°C, not all medication was dated on opening, and internal and external medication should be stored separately. The inspector spoke with the manager and suggested that where creams are held in resident’s bedrooms that a MAR (medication, administration record) sheet is maintained in the room in a discreet place this should help in preventing missed signatures on the main MAR sheet. Risk assessments were in place for creams in rooms but those examined needed to be reviewed. The main MAR sheet should contain detail that a further MAR sheet is maintained elsewhere, and this should be signed and dated by the author. No controlled drugs were being held at the time of this inspection. Courtland Lodge DS0000019325.V280582.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): These standards were not inspected on this occasion. EVIDENCE: Please see inspection report dated 14th June 2005 for comments. Courtland Lodge DS0000019325.V280582.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 & 18 Robust procedures are in place to ensure the protection of the residents. EVIDENCE: A copy of the complaints procedure is available. Residents were aware of whom to speak to if they had any concerns or were unhappy with the care provided. Six complaints/concerns had been received since the last inspection. These had appropriately recorded with actions and outcomes. Adult protection is covered in the induction programme and additional training is organised as required. Courtland Lodge DS0000019325.V280582.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 & 26 The home is clean and reasonable well maintained, although some areas are in need of redecoration. Regular maintenance checks are carried out on service and equipment. The laundry is in need of a major overhaul and possible hazards have been identified during this inspection. EVIDENCE: The home was clean and tidy on the day. The manager has ordered new seating for one lounge and fifteen for the bedrooms. Staff were in the process of decorating and equipping the respite bedrooms, these were looking very homely and welcoming. There are still areas of the home that were in need of redecorating where the woodwork had been damaged through general wear and tear, some of the borders and wallpaper had been torn. Bathrooms are also in need of some attention where the baths are stained and flooring has become loose. Some carpets were stained and frayed in some places. Courtland Lodge DS0000019325.V280582.R01.S.doc Version 5.1 Page 14 The laundry room is in need of major redecoration as the floor covering is worn and damaged; there are broken wall tiles, ceiling paint has blistered, the window is cracked, basins are in need of descaling/cleaning, worktops are in need of replacing, paintwork has blistered on the walls where no tiles are fitted. A dryer is out of action. It is worth consulting staff on what equipment is used and if machinery is to be moved the best place to put it should also be considered. The ironing roller that has been purchased appears to be of poor design as staff are suffering with pain in their hips and backs after using it. The inspector also found the same when they simulated the action. Discussions took place with staff and the manager about considering the use of a perching stool. A risk assessment should be put in place to protect the health, safety and welfare of staff. Policies and procedures are in place for the control of infection to ensure the protection of both residents and staff. Courtland Lodge DS0000019325.V280582.R01.S.doc Version 5.1 Page 15 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 & 29 Robust procedures are in place for the protection of the people living in the home. Sufficient numbers and the deployment of staff were adequate to meet the personal care needs of the residents at the time of this inspection. EVIDENCE: Staff files examined showed that all the relevant checks had been carried out prior to the beginning employment at the home. Adequate numbers of care staff, domestic and catering staff were available to look after the 56 residents. Observation of staff at work concluded that they were knowledgeable about the needs of the residents. Residents spoken to stated “this is a very nice place and the staff give us what we need”. Courtland Lodge DS0000019325.V280582.R01.S.doc Version 5.1 Page 16 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 & 38 The manager has settled in well although an application has been received she is not yet registered with the Commission For Social Care Inspection. Health & safety is well managed and ensures that everyone entering Courtlands Lodge is protected. EVIDENCE: The manager has been in post since August 2005. Commission For Social Care Inspection has received an application and the process for registration has begun. She undertakes periodic training to maintain her skills and competency. The manager is supported by a number of care team managers. The manager is aware of her role and responsibilities in running the home. All accidents and incidents are documented appropriately and a monthly audit is carried out. Appropriate fire checks have been carried out and recorded. Courtland Lodge DS0000019325.V280582.R01.S.doc Version 5.1 Page 17 Comprehensive policies and procedures are in place to ensure the health, safety and welfare of all who enter Courtlands Lodge is promoted and protected. Regulation 26 reports are carried out although these are not receive by the Commission For Social Care Inspection in a timely manner, the last received was in October 2005. The organisation must ensure that the Commission For Social Care Inspection receives them on a monthly basis. Courtland Lodge DS0000019325.V280582.R01.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 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 2 X X X X 3 Courtland Lodge DS0000019325.V280582.R01.S.doc Version 5.1 Page 19 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 OP19 Regulation 23(2)(b) & (d) Requirement The manager must ensure that the redecoration plan continues and that all areas of the home are brought up to an acceptable standard. This has been brought Timescale for action 31/05/06 forward from the previous inspection and a new timescale set. 2 OP26 23 (2)(b)(c)& (d) 26 3 OP33 The laundry room must be redecorated and brought up to an acceptable standard and all machines should be in full working order The proprietor must ensure that reports are received by the Commission For Social Care Inspection every month 30/04/06 28/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations Staff should ensure daily records are kept up to date and reflect the needs identified in the care plan. DS0000019325.V280582.R01.S.doc Version 5.1 Page 20 Courtland Lodge 2 OP9 3. OP12 Any areas of need that have been highlighted should be monitored and recorded appropriately Prescribed medication should be stored at the correct temperature as per the manufacturers instructions. Internal & external medication should be stored separately. The manager should investigate the possibility of getting a second activity co-ordinator to provide more time to individual residents especially those who suffer from dementia. Courtland Lodge DS0000019325.V280582.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ 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. 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