Inspection on 09/01/07 for Epsom Lodge

This inspection was carried out on 9th January 2007.

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 08/11/05

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 Mary Williamson Unannounced Inspection 9th January 2007 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.V325446.R01.S.doc Version 5.2 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.V325446.R01.S.doc Version 5.2 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 10 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (7) of places Epsom Lodge DS0000013638.V325446.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Three of the ten service users may also have a sensory impairment SI(E) 8th November 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. The fees charged range from £500 to £550. Epsom Lodge DS0000013638.V325446.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and was undertaken by Mary Williamson who is a Regulation Inspector. The registered home manager Mrs Helen Pugh was present for the duration of the inspection. It was possible to meet all the service users and to talk with some service users in more detail then others. A tour of the premises was undertaken and records relating to the care of the service users and the management of the home were examined. It was possible to have a discussion with the cook who was the only member of staff present during the inspection. The manager completed a pre inspection questionnaire and nine service users comment cards and nine relative/visitor comment cards were returned to the inspector prior to the inspection. The inspector would like to thank the service users, manager, and the cook for their help and hospitality during the inspection. What the service does well: The home provides a good standard of accommodation and support to service users in a homely and relaxed atmosphere. Needs are assessed and outlined in well-maintained care plans. Health care needs are met and there is good support from a variety of health care professionals. Family links and community participation are maintained. The catering arrangements are good and a varied and nutritional menu is in place. All service users spoken to had positive comments regarding the standard of the food. The home is well managed by an experienced manager. Epsom Lodge DS0000013638.V325446.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Epsom Lodge DS0000013638.V325446.R01.S.doc Version 5.2 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.V325446.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, and 6. Quality in this outcome area is (good). This judgement has been made using available evidence including a visit to this service. All prospective service users have access to sufficient information in order to help them make an informed choice about living in the home. Needs assessments and contracts of occupancy are in place. EVIDENCE: All the service users and their families have a copy of the statement of purpose and the service user guide prior to admission to the home in order to help them make an informed decision about living in the home. There is also a copy of this in individual bedrooms. The manager explained that she undertakes a full needs assessment on all prospective service users to establish the suitability of the placement. Epsom Lodge DS0000013638.V325446.R01.S.doc Version 5.2 Page 9 These assessments are usually carried out by inviting service users to spend a day at the home, although some assessments may be done in hospital. Needs assessments were seen for WP, MR, and JC, which are detailed and informative. Contract of occupancy are in place and outline the care to be provided, accommodation offered, and the amount, method and frequency of fees paid. The home does not provide intermediate care. Epsom Lodge DS0000013638.V325446.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, and 10. Quality in this outcome area is (good). This judgement has been made using available evidence including a visit to this service. The arrangements in place are appropriate to meet the health, personal, and medication needs of service users as outlined in individual care plans. EVIDENCE: Care plans were seen for MR, WP, and JC, which outline how individual care is carried out. These are well maintained and reviewed every three months or more frequently if needs change. Risk assessments for mobility needs, walking outside the home and bathing are also included in care plans. All service users are registered with a local GP who will visit on request. There is also a good district nurse support who will undertake procedures for example skin risk assessments, dressings when required and administer flu vaccines. The chiropodist visits the home every six weeks. The mobile optician service make regular visits and the dentist also provides a domiciliary service. Epsom Lodge DS0000013638.V325446.R01.S.doc Version 5.2 Page 11 The home has a privacy and dignity policy in place and staff are made aware of this policy during their induction training. There is a policy in place for the administration of medication. All the staff who administer medication are familiar with this policy. Anachem Pharmacy supply all the medication to the home. The blister pack format is in use. The pharmacy also undertakes regular audits of medication and the training for the staff. The medication recording charts were seen and are well maintained. Medication is stored safely, and there are no controlled drugs in use. Currently there are no service users in the home that self medicate. Epsom Lodge DS0000013638.V325446.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, and 15. Quality in this outcome area is (good). This judgement has been made using available evidence including a visit to this service. The arrangements for social and leisure activities meet individual and collective needs of service users. Service users receive a varied and nutritional diet. EVIDENCE: There is an activities programme in place, which includes gardening, model making, flower arranging, embroidery, library, music TV and video. The home also engages the services of an activities person who organises music and exercises classes and gentle exercises classes. Several service users were looking forward to this activity, which was due to take place later in the afternoon of the inspection. Three service users said they like to read their daily paper and two service users stated that they prefer their own company. Family and community links are maintained. Several service users told the inspector that they went out with their family either Christmas Day or Boxing Day. The manager stated that visitors are welcome in the home at any Epsom Lodge DS0000013638.V325446.R01.S.doc Version 5.2 Page 13 reasonable time and are included in the care planning process. The relative feedback forms received prior to the inspection confirmed this. There is a Church of England Holy Communion Service organised every Thursday morning in the home followed by a coffee morning. Arrangements can be made for members of various clergy to visit the home on request. The menus were seen and are varied and nutritional. The cook plans these over a four-week period, with input from the service users. Lunch was observed and consisted of pork casserole, carrots, cabbage, potatoes, followed by lemon and sultana sponge and custard. There were very favourable comments by the service users on the standard and quality of the food. The kitchen was clean and orderly and all the relevant records relating to food safety were in place. The last Environmental Health inspection took place in May 2006 and was satisfactory. Epsom Lodge DS0000013638.V325446.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is (good). This judgement has been made using available evidence including a visit to this service. The complaints and abuse awareness procedures in place protect the service users living in the home. EVIDENCE: The home has a complaints procedure in place and all service users and their relatives have access to a copy of this, which is included in the service users guide. There have been no recorded complaints since the last inspection. One service user stated that he was satisfied with the procedure and felt sure that if he had to make a complaint that this would be acted upon. The home has an abuse awareness policy in place and all staff have training in this policy during induction training. There is also a copy of Surreys Multi Agency Policies and Procedures on Safeguarding Vulnerable Adults in place and the providers, manager, and senior carers have attended training organised by the local authority in these procedures. Epsom Lodge DS0000013638.V325446.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, and 26. Quality in this outcome area is (good). This judgement has been made using available evidence including a visit to this service. Service users live in a safe comfortable and homely environment. The standard of cleanliness and maintenance is good with the exception of the shower room floor, which is in need of replacing. EVIDENCE: The home is clean and tidy and free from offensive odour. It meets the individual and collective needs of the service users. There is a comfortable open plan lounge/dining room providing ample communal space for the service users. This overlooks a well -maintained garden, which is looked after by the providers and a service user. Bedrooms are of single occupancy with the exception of one double room. These rooms are comfortably furnished and have been personalised to reflect Epsom Lodge DS0000013638.V325446.R01.S.doc Version 5.2 Page 16 individual personalities. Service users are encouraged to bring personal items with them on admission to the home. There is an assisted bathroom on the first floor and a shower room on the ground floor to meet the assessed mobility needs of the service users. The shower room floor is in a state of disrepair and needs to be replaced. There is a ramp access to the garden and grab rails situated at the end of the stairs and at the steps by the front door. The home has an infection control policy in place, and arrangements are in place for the collection of clinical waste. Epsom Lodge DS0000013638.V325446.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, and 30. Quality in this outcome area is (adequate). This judgement has been made using available evidence including a visit to this service. The number and skill mix of staff on duty was not sufficient to meet the service users needs during the inspection. The recruitment procedure and the training programme in place are satisfactory. EVIDENCE: The duty rota was seen and the number and skill mix of the staff on duty did not reflect that recorded on the duty rota. One of the providers and a senior carer were scheduled to work but the manager and the cook were the only staff in the home during the inspection. The manager stated that there are at least two staff on duty throughout the day and one care staff for a sleep in shift four nights a week and the providers cover the remaining three nights between them. Both providers had gone shopping and the carer had to go home to a domestic emergency. A requirement has been made regarding the staffing levels. The recruitment procedures in place are satisfactory. Staff employment files were seen for IH, SB, SG, and NT. These are well maintained and include all Epsom Lodge DS0000013638.V325446.R01.S.doc Version 5.2 Page 18 the required information including a CRB (Criminal Records Bureau) disclosure number. Staff training is ongoing and is coordinated by Loving Care Training Consultants. All staff undertake induction training evidence of which was seen in individual files. NVQ training is ongoing with some staff having achieved NVQ Level 3 and some staff currently undertaking NVQ Level 2. The cook confirmed that she has a current food hygiene certificate and has undertaken health and safety training and fire safety training. Epsom Lodge DS0000013638.V325446.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 35, and 38. Quality in this outcome area is (good). This judgement has been made using available evidence including a visit to this service. The service users live in a home which is well managed and that promotes their health and welfare. EVIDENCE: The home is well managed by the registered manager who has considerable experience in the provision of care of older people. She has been in post for two and a half years and is currently undertaking her Registered Managers Award. The manager’s role is very much a hands post. Epsom Lodge DS0000013638.V325446.R01.S.doc Version 5.2 Page 20 Both providers live on site and form part of the staffing levels and the management of the home. One provider is also undertaking his Registered Managers Award. During discussion with service users they all spoke highly of the manager and the providers and the support they receive. This has also been confirmed in the service user and relative comment cards returned to the inspector prior to the inspection. The manager explained that personal money is not managed in the home. She stated that fees are paid by direct debit or by cheque to the provider’s business account. Toiletries, hairdressing, chiropody, newspapers and sundries not included in fees are purchased by the home and an invoice sent to the service users or their designated representative. Health and safety policies and procedures were seen throughout the inspection and these promote the health and welfare of the service users. Risk assessments are in place for all identified risks to include safe working practice. All staff undertake health and safety training during induction training, which includes manual handling, food hygiene, first aid, fire safety and COSHH. Fire safety records are maintained and include records of weekly alarm testing. Stand By Fire Protection contractors maintain the fire fighting equipment and emergency lighting. Surrey Fire Service undertook a risk assessment in the home on 20/11/2006. Epsom Lodge DS0000013638.V325446.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X 3 X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X 3 Epsom Lodge DS0000013638.V325446.R01.S.doc Version 5.2 Page 22 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 OP21 Regulation 23(2)(b) Requirement Timescale for action 09/01/07 2 OP27 18(1)(a) The registered person must ensure that all parts of the care home are kept in a good state of repair including the shower/toilet floor. The registered person must 09/01/07 ensure that suitably qualified and competent staff are working in the home at all times to meet the assessed needs of the service users. This should also include a back up procedure for emergencies. 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 Epsom Lodge DS0000013638.V325446.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V325446.R01.S.doc Version 5.2 Page 24 - 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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