Inspection on 08/11/05 for Epsom Lodge

This inspection was carried out on 8th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Epsom Lodge 09/01/07

Epsom Lodge 09/05/05

Epsom Lodge 01/09/04

Epsom Lodge 03/06/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Epsom Lodge Epsom Lodge 1 Burgh Heath Road Epsom Surrey KT17 4LW Lead Inspector Peter Benthom Unannounced Inspection 8th November 2005 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 Epsom Lodge DS0000013638.V252250.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. Epsom Lodge DS0000013638.V252250.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Epsom Lodge Address Epsom Lodge 1 Burgh Heath Road Epsom Surrey KT17 4LW 01372 724722 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) Mr Kevin John Middleton Ms Ninawatie Seepaul Mrs Helen Pugh Care Home 9 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (9) of places Epsom Lodge DS0000013638.V252250.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Three of the nine service users may also have a sensory impairment SI(E) 9th May 2005 Date of last inspection Brief Description of the Service: Epsom Lodge is a large detached house, situated close to the local amenities of Epsom. The home provides accommodation and personal care for up to ten service users in the category of older people, three of who may in the category of dementia. The accommodation consists of eight single rooms and one for double occupancy, a dining room/ lounge and appropriate laundry and kitchen facilities. Service users’ bedrooms are on the ground and first floors of the building, the proprietors live on the second floor. A passenger lift enables service users on the first floor to access their bedrooms at all times. A garden is situated to the rear of the home, and a small parking area is available at the front of the property. Epsom Lodge DS0000013638.V252250.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second inspection to be undertaken by the Commission for Social Care Inspection for the year April 2005 to March 2006. For details of how each standard was met please refer to the main body of the report. It will be necessary to review both inspection reports for 2005-06 to obtain a full understanding of the extent to which the home meets The National Minimum Standards for Older People. The inspector had the opportunity to speak with a number of service users who live at the home. All service users were complimentary about the home and spoke affectionately of the manager and staff. Recently admitted service users were spoken with during the course of the inspection. The staff were observed to be courteous and the atmosphere within the home was relaxed and friendly. The home was in good decorative order. All service users were spoken with on the day of the inspection. What the service does well: What has improved since the last inspection? The home has varied its category since the last inspection and is now registered to care for three (3) people with dementia. The manager has been able to access up to date training for staff in the care of older people with dementia. This will take place on 24 November 2005. There is a commitment from the proprietors to offer as much opportunity as possible to staff to undertake appropriate training. Epsom Lodge DS0000013638.V252250.R01.S.doc Version 5.0 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. Epsom Lodge DS0000013638.V252250.R01.S.doc Version 5.0 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 Epsom Lodge DS0000013638.V252250.R01.S.doc Version 5.0 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, 2, 3, 4 and 5 Service users are admitted only following a full assessment undertaken by people trained to do so. The registered person was able to demonstrate the homes capacity to meet the assessed needs. EVIDENCE: All potential service users are assessed prior to admission. It was reported that the service only admits new service users based on an assessment of needs, and appropriateness of placement The initial assessment was used to form the basis of the care and the support plan, which identified the actions that carers should follow to assist an individual living at the home. Service users and their families/representatives and relevant professionals are involved in the assessment process. There have been three recent admissions to the home and the manager has carried out the assessments satisfactorily. Written documentation was examined and found to be in good order. Epsom Lodge DS0000013638.V252250.R01.S.doc Version 5.0 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 10 Health, personal and social care needs are effectively met in this home. Service users’ health needs were well met and medication administration was accomplished satisfactorily. EVIDENCE: Encouragement and support was given to service users to promote independence within the limitation of each individual’s capabilities The manager stated that all service users were registered with the local GP practice for the provision of general medical services. Recently admitted service users will be given the opportunity to be registered with the homes GP. During the inspection the staff cared for Service Users in a respectful manner. Those Service Users requiring any assistance were helped sensitively. All Service Users have their own bedroom, thus providing the opportunity for privacy when visitors arrive, whether family or professionals. The Homes’ policies and procedures placed particular emphasis on the core values of caring, such as independence, privacy and dignity. Epsom Lodge DS0000013638.V252250.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, 13, 14 and 15 Links with the local community are good and serve to enrich Service Users lives. Limited activity programmes were in place, and service users were able to maintain contact with friends and family. Menus provided wholesome home cooked food. EVIDENCE: Links with the local community are good and serve to enrich Service Users lives. Limited activity programmes were in place, and service users were able to maintain contact with friends and family. Limited activity programmes were in place, and service users were able to maintain contact with friends and family. A more regular and focussed programme of activities needs to be organised as some service users said they felt bored sometimes. Please see requirements on Page 20 of this report. Epsom Lodge DS0000013638.V252250.R01.S.doc Version 5.0 Page 11 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, 17 and 18 The home has a satisfactory complaints system that is made available to all Service Users and staff. EVIDENCE: There have been no complaints since the last inspection. The home has a complaints book, and service users know that if they have any problems, the proprietors are on the premises, and they can make their concerns known to them. The complaints procedure is included in the Statement of Purpose and the Service Users guide. Staff are aware of abuse and stated that they would have no hesitation voicing their concerns. The home has a whistle blowing policy in place. Epsom Lodge DS0000013638.V252250.R01.S.doc Version 5.0 Page 12 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, 21, 22, 23, 24, 25 and 26 The standard of décor and equipment in this home is very good with evidence of improvement through continual maintenance and refurbishment. EVIDENCE: The location of the home is suitable for its stated purpose; it is accessible, safe and well maintained, meeting service users’ individual and collective needs in a comfortable and homely way. All areas were found to be clean, tidy and well organised. The garden was observed to be well maintained and easily accessible. The home had spacious communal sitting and dining areas. All areas met the required standard and were tastefully decorated and furnished. Specialist bathing facilities and additional toilets were provided suitable to meet the needs of the service users and in close proximity to communal areas and bedrooms. All rooms were clean and adequately ventilated. Epsom Lodge DS0000013638.V252250.R01.S.doc Version 5.0 Page 13 Standards of cleanliness in the kitchen in particular, were seen to be very high. Staff were reminded that the use of bleach as a cleaning agent is prohibited within COSHH regulations. Epsom Lodge DS0000013638.V252250.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, 28, 29 and 30 The staff had a good understanding of Service Users need. This was evident from the positive relationships that have been formed between staff and Service Users. Staff are aware of all aspects of protection of vulnerable people and appropriate up to date training is in place. EVIDENCE: The home is staffed at previously agreed levels. The manager and the one of the proprietors has commenced NVQ Level 4 and the Registered Managers Award. There is low staff turnover in this Home and there are appropriate training opportunities in place for staff. Dementia care training is taking place on 24 November 2005. Night staff have been appointed since the last inspection and it was noted that they currently do not write reports. This must be addressed as soon as possible and a report must be provided at the beginning and end of each shift. Epsom Lodge DS0000013638.V252250.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, 32, 33, 34, 35, 36, 37 and 38 The manager is supported by the proprietors in providing clear and consistent leadership in the home with staff illustrating an awareness of their roles and responsibilities EVIDENCE: The home’s manager is experienced, and capable of running the home. She is studying for NVQ Level 4 and the Registered Managers Award. Epsom Lodge DS0000013638.V252250.R01.S.doc Version 5.0 Page 16 The management of the home was observed to be open and inclusive. There was a positive, friendly and relaxed atmosphere. Service Users spoken with stated that they are content with the service provided. Service Users were observed to be settled and happy in their environment. One of the proprietors commenced the RMA in September of 2005. The homes policies and procedures have been updated and risk assessments are reviewed on a regular basis for all service users. New staff are given a thorough induction programme, which they have to follow. The proprietors of the home who live on site audit the home on a regular basis. Epsom Lodge DS0000013638.V252250.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 3 3 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 2 3 Epsom Lodge DS0000013638.V252250.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. Standard Regulation 16 (2)(m) Requirement It is required that a more varied programme of activities is provided for all service users It is required that night staff complete a written report on ALL service users at the beginning and end of each shift Timescale for action 08/12/05 2 17 (1)(a) Schedule 3 08/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard N/a Good Practice Recommendations There are to be no recommendations from this report Epsom Lodge DS0000013638.V252250.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Epsom Lodge DS0000013638.V252250.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. 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