CARE HOMES FOR OLDER PEOPLE
Epsom Lodge 1 Burgh Heath Road Epsom Surrey KT17 4LW Lead Inspector
Mr P Benthom Announced Inspection 09 May 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Epsom Lodge H58 H09 s13638 epsom lodge v212393 090505 Stage 4 ann.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Epsom Lodge Address 1 Burgh Heath Road, Epsom, Surrey. KT17 4LW 01372 724722 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Kevin John Middleton Ms Ninawatie Seepaul Mrs Helen Pugh CRH (PC) 9 Category(ies) of Old age, not falling within any other category registration, with number (OP) 9. of places Epsom Lodge H58 H09 s13638 epsom lodge v212393 090505 Stage 4 ann.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: Three of the nine service users may also have sensory impairment SI(E). Date of last inspection 01 September 2004 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 nine service users in the category of older people. The accommodation consists of nine single rooms, 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 garden is situated to the rear of the home, and a small parking area is available at the front of the property. Epsom Lodge H58 H09 s13638 epsom lodge v212393 090505 Stage 4 ann.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was the first of the year 2005/6 and was conducted by an inspector from CSCI. Four of the Service Users were spoken with during the course of the inspection. A tour of the premises took place and care; training and Health and Safety records and staff rotas were inspected. What the service does well: What has improved since the last inspection?
Epsom Lodge H58 H09 s13638 epsom lodge v212393 090505 Stage 4 ann.doc Version 1.30 Page 6 The maintenance of accurate medication records and the redesigning of care plans has taken place since the last inspection. Service users’ health needs were well met and medication administration was accomplished satisfactorily. The service plans in place were comprehensive and were all reviewed regularly, The home has a comprehensive complaints procedure, which is given to all service users on admission. It was positive to hear that service users and visitors felt able to make their concerns known to the proprietors. The vulnerable adults procedures were known to staff who also demonstrated a commitment to using them should they have a concern. 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 H58 H09 s13638 epsom lodge v212393 090505 Stage 4 ann.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Epsom Lodge H58 H09 s13638 epsom lodge v212393 090505 Stage 4 ann.doc Version 1.30 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 4, 5 and 6 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: The home had a comprehensive statement of purpose, which depicted the services provided by the home. However this is in need of some updating in order to ensure that it accurately illustrates the services that the home has to offer. Service users were very complementary about the care they received and considered the home met their needs well. Potential service users are only admitted after the manager completes a thorough assessment. The home has a detailed form for assessments. Epsom Lodge H58 H09 s13638 epsom lodge v212393 090505 Stage 4 ann.doc Version 1.30 Page 9 The home would only accept placements based on the assessment of the service user, and also the resources available in the home. The home is not able to accommodate wheelchair users. All service users must be mobile. Prospective service users are encouraged to visit the service to have a look around, have lunch and talk with existing service users. The service provides the potential service user a trial period of six weeks, however this period of time may be extended if requested. Service users are provided with a statement of terms and conditions when first entering the home. This document is kept on all service users’ files. Epsom Lodge H58 H09 s13638 epsom lodge v212393 090505 Stage 4 ann.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 10 Health, personal and social care needs are adequately met in this home. EVIDENCE: Service Users’ care plans are drawn up from the perspective of the Service User and showed their individual preferences, likes and dislikes. New Service Users when admitted to the home are assessed accordingly. They are given the opportunity to stay overnight prior to their permanent admission. Evidence that Service Users’ optical, dental and chiropody needs are met and confirmed in the diary and other records. There were facilities and procedures available for the safe reception, storage, disposal, administration and recording of medication. Service users are registered with two surgeries locally, and the GP’s offer the home a good service, and are available when needed. The home has clear guidelines for staff to follow to ensure the privacy and dignity of all service users. The manager and staff are aware of the need to respect service users, and were seen to be treating the service users with respect and consideration on the day of the inspection. Epsom Lodge H58 H09 s13638 epsom lodge v212393 090505 Stage 4 ann.doc Version 1.30 Page 11 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 15 Service Users views are sought from time to time, but there was no evidence to suggest that these views were acted upon. EVIDENCE: There were no restrictions placed on visitors and those present at the time of the inspection were made welcome by management and staff. Whilst the home does not have a designated visitor’s area privacy during visits may be secured using service users’ rooms. There were no restrictions placed on visitors and those present at the time of the inspection were made welcome by management and staff. The manager stated that service users enjoy sitting in the garden during the summer, and that the home makes full use of its outdoor area in the good weather. Visitors stated that they are always welcome, and families are in the home every day, and take service users to the near by town and to the park opposite. The home has a four weekly menu with input from the service users. The home uses fresh food, and service users were seen taking their breakfast in the dining room. Staff were seen assisting service users in a relaxed and unhurried manner. Epsom Lodge H58 H09 s13638 epsom lodge v212393 090505 Stage 4 ann.doc Version 1.30 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 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 have received up to date training in the protection of vulnerable adults.. 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 H58 H09 s13638 epsom lodge v212393 090505 Stage 4 ann.doc Version 1.30 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 standard(s) 19, 20, 21, 22, 23, 24, 25 and 26 The standard of the environment within this home is good providing Service Users with an attractive and homely place to live. EVIDENCE: Overall the home was in good condition; appropriately decorated, well maintained and furnished to a high standard. The secluded garden is particularly attractive and of a large size, stocked with garden furniture. Several bedrooms were seen during the inspection. These were each highly personalised and individual in style. Some of the bedrooms had photographs and other items linked to the Service Users family life outside the home. There were sufficient bathrooms and toilets to meet the national minimum standard. The communal areas in the home were considered safe and accessible for the Service Users. The home was clean and free from offensive odours.
Epsom Lodge H58 H09 s13638 epsom lodge v212393 090505 Stage 4 ann.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30 Staffing levels are inconsistent in providing a safe environment for Service Users at night EVIDENCE: The home is staffed at previously agreed levels. There are two staff on duty during the day. However, at night there is insufficient safe cover and the resident proprietors provide any support that may be necessary. This involves the home being inadequately covered in the event of an emergency as evacuation of the premises would fall solely upon the proprietors. It was concluded that the current staffing levels are sufficient during the waking day, but not at night. It is the expectation of the Manager that 50 of the care staff will achieve NVQ Level 2 by the end of 2005. 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. Agency staff are not used and gaps in the rota are covered by existing staff members. There are arrangements to carry out Criminal Records Bureau checks and two written references are required for all staff. There was evidence that all staff had had some mandatory training for the year and that other appropriate training had been booked leading up until the end of 2005.
Epsom Lodge H58 H09 s13638 epsom lodge v212393 090505 Stage 4 ann.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 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/proprietor is experienced, and capable of running the home. She is studying for NVQ Level 4 and the Registered Managers Award. Epsom Lodge H58 H09 s13638 epsom lodge v212393 090505 Stage 4 ann.doc Version 1.30 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 is also to commence the RMA in September this year. 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. All cleaning chemicals are locked up in accordance with COSHH requirements. Epsom Lodge H58 H09 s13638 epsom lodge v212393 090505 Stage 4 ann.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 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 3 13 3 14 3 15 3
COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 3 3 3 3 3 3 3 Epsom Lodge H58 H09 s13638 epsom lodge v212393 090505 Stage 4 ann.doc Version 1.30 Page 18 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 18(1)(a) Regulation OP27.5 Requirement It is required that adequate arrangements are made for designated staff to be available at night to provide sufficient assistance to Service Users when necessary It is required that the homes Statement of Purpose be reviewed to include accurate information of the services that the home provides Timescale for action 30/6/05 2. 4(1)(b) OP1.2 30/6/05 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 Good Practice Recommendations There are to be no recommendations from this inspection Epsom Lodge H58 H09 s13638 epsom lodge v212393 090505 Stage 4 ann.doc Version 1.30 Page 19 Commission for Social Care Inspection 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 H58 H09 s13638 epsom lodge v212393 090505 Stage 4 ann.doc Version 1.30 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
