CARE HOMES FOR OLDER PEOPLE
Gate Lodge 1 Upper Woodcote Village Purley Surrey CR8 3HE Lead Inspector
Peter Stanley Announced Inspection 16 June 2005 9:30am 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. Gate Lodge G53 S25784 GateLodge V189106 160605 stage4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Gate Lodge Address 1 Upper Woodcote Village, Purley, Surrey, CR8 3HE 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) 020 8668 7286 gatelodgeresthome@yahoo.co.uk Mr Paramaseeven Chellun Mrs Georgia Chellun Mrs Christina Thambirajah Care Home 16 Category(ies) of Dementia - over 65 (16) registration, with number of places Gate Lodge G53 S25784 GateLodge V189106 160605 stage4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: For people with dementia who are over 65. Date of last inspection 4 January 2005 Brief Description of the Service: Gate Lodge is an attractive detached property located on the green of Upper Woodcote Village within a pleasant residential area. The home is within walking distance of a small village shop and is surrounded by several larger houses. The home has 12 single rooms and two double rooms located on two floors, ground and first floor and there were sixteen service users in residence at the time of inspection. Gate Lodge has two adjoining lounge areas and a separate dining room. The home does not have a lift and thus access between the ground and first floor is by stairs.There is parking for three cars to the front, and parking is also available on the road outside the home. There is a well-kept garden available for the service users. Gate Lodge G53 S25784 GateLodge V189106 160605 stage4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This announced inspection was conducted over one day and involved discussion with the registered manager, Mr Parmaseeven Chellun, the registered manager, Mrs Christina Thambirajah, staff on duty and service users. The registered provider’s son, Mr Jason Chellun, who is assisting with the management of the home, was also present. The inspector noted that of the 21 requirements identified in the previous inspection report, 15 have now been met. There are 6 requirements which remain to be met together with 6 new requirements from this inspection, making 12 in total. There are also 3 recommendations from this inspection. What the service does well:
Generally, service users presented as very settled and satisfied, there being a good atmosphere in the home. Many positive comments were made to the inspector regarding the home and the support provided. The management and staff were observed to interact with the service users in a caring, respectful and professional manner. Service users’ healthcare needs are being fully met, with comprehensive health care information being recorded. Service users are having their health, personal and social care needs set out in an individual plan of care, with review taking place on a monthly basis. Risk assessments are being completed. The home has an appropriate complaints policy and procedure in place. Clear information for raising complaints is made available, and service users and their relatives/friends are able to raise any concerns they may have. The inspector is satisfied that service users are living in a safe, well-maintained environment, and that the health, safety and welfare of service users and staff are being appropriately promoted and protected. There is access to safe and comfortable facilities. Risk assessment of the home and individuals are in place for their protection. A number of health and safety requirements from the previous inspection have been met, though a fire safety check of furniture and furnishings remains to be evidenced. All health and safety checks and certification are in place. Gate Lodge G53 S25784 GateLodge V189106 160605 stage4.doc Version 1.30 Page 6 Service users’ rooms were observed to be safe, comfortable and pleasantly decorated, reflecting service users’ personal identities, and being suited to their individual needs. An audit of all service users’ bedrooms has been completed, with some items of furniture having been added or replaced. The home presents as clean, pleasant and hygienic. All staff have now undertaken infection control training. There has been renovation and redecoration of the laundry so as to facilitate improved standards of hygiene. The home is evidenced to have the numbers and skill mix of staff sufficient to meet the needs presented by the home’s service users, and to ensure their safety. The registered manager presented as a fit person to be in charge, with the necessary skills and experience with which to manage the home in the best interests of the home’s service users. The registered provider’s son is presently assisting the manager with the running of the home and is intending to become more involved in the home’s management. The management approach was observed to be conducive to creating an open, relaxed and friendly atmosphere. What has improved since the last inspection?
This home had 21 requirements from the last inspection, 15 of which have now been met. This represents a significant overall improvement. There have been a number of health and safety concerns which have been addressed. This includes the installation of protective covers on all radiators , the assessment of the home for aids and adaptations by an occupational therapist, and the implementation of an audit of furniture and furnishings in service users’ bedrooms (with the replacement of faulty or worn items). The home has developed an annual maintenance and development programme for 2005 since the last inspection and is maintaining monthly maintenance checks and records. Staff have completed infection control training in line with a requirement from the last inspection. More attention is being given to the training of staff, with training having been updated to cover a number of key areas including moving
Gate Lodge G53 S25784 GateLodge V189106 160605 stage4.doc Version 1.30 Page 7 and handling, medication, dementia awareness, first aid, food hygiene and infection control. Statutory adult protection training is, however, required and a training plan still needs to be put in place. While there has been an overall improvement in this home, this progress needs to be sustained if the concerns that have been identified are to be fully addressed. What they could do better:
While the home has been able to demonstrate that a service user’s needs have been properly assessed for a recent admission, the home must ensure that care management assessments are obtained prior to any admission which involves referral from social services. While appropriate medication policies and procedures are in place, there must be risk assessment of any service users who self-medicate. The protection of service users will only be ensured once a requirement has been met for accredited medication training to be extended to all care staff. A separate locked safe for controlled drugs is required. While the home has appropriate adult protection policies and procedures in place, providing protection for service users, staff awareness of local multiagency adult protection procedures must be raised through attending Croydon’s statutory vulnerable adult training. While the home has appropriate recruitment policy and procedures in place, there have been concerns regarding the completion of staff recruitment checks on this and previous inspections. While the home is showing greater vigilance in completing checks, it was found that a CRB (Criminal Records Bureau) check had not been obtained for one appointment, and only one suitable reference obtained for another. This is potentially compromising the protection and safety of service users. The home is failing to provide regular supervision for staff. This is detrimental to the support and development of staff and is potentially compromising the protection and safety of service users. There is an outstanding requirement for regular supervision which must be met. The home must ensure that the training needs of staff are fully met. A year on year training plan must be developed which outlines the areas of training identified for staff and the training completed and scheduled.
Gate Lodge G53 S25784 GateLodge V189106 160605 stage4.doc Version 1.30 Page 8 The home must continue to develop its quality assurance processes so as to demonstrate that it is meeting its aims and objectives. Feedback from service users needs to be extended to include relatives/friends of service users, relevant care managers/professionals and other stakeholders. A development plan, outlining the home’s forward plans, must be put in place. While the home has complied with a number of health and safety requirements from the previous inspection, a fire safety check of furniture and furnishings remains to be evidenced. 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. Gate Lodge G53 S25784 GateLodge V189106 160605 stage4.doc Version 1.30 Page 9 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 Gate Lodge G53 S25784 GateLodge V189106 160605 stage4.doc Version 1.30 Page 10 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) 2, 3 and 6 Service user’s needs are now properly assessed prior to moving into the home. However in order that service users and their representatives can be confident that the home will meet their needs, all the information essential to making an assessment must be available prior to a decision being made and moving into the home. Each service user is being provided with a copy of their contract or terms and conditions at the point of moving into the home. EVIDENCE: The inspector was shown copies of service users’ contracts which are kept on a separate file. The Registered Provider stated that all service users are provided with a copy of their contract or terms and conditions at the point of moving into the home. This needs to be recorded on the service user’s file and a copy of the contract/terms and conditions included. All service users must be provided with a statement of their contract or terms and conditions. The
Gate Lodge G53 S25784 GateLodge V189106 160605 stage4.doc Version 1.30 Page 11 contract/statement of terms and conditions must include all elements of standard 2.2 The inspector examined the file of a recently admitted service user, who is self-funding, and found that pre-admission assessments had been completed by the home. The last inspection evidenced that care management assessments had not been obtained for a number of admissions. The Registered Manager and Registered Provider are reminded that new service users must only be admitted to the home on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representative (if any) and relevant professionals have been party to. All care managers assessments or those of the home in respect of self funding service user’s must contain all elements of standard 3.3. While the requirement has been removed, this standard will be closely monitored at the next and subsequent inspections, so as to ensure compliance. The home does not provide intermediate care. Gate Lodge G53 S25784 GateLodge V189106 160605 stage4.doc Version 1.30 Page 12 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 and 9 Service users are having their health, personal and social care needs set out in an individual plan of care which is risk assessed and reviewed monthly. Which gives assurance to the service users and their representatives that these needs are being met Service users’ healthcare needs are being fully met and are with three exceptions, generally being protected by the home’s policies and procedures and practice in respect of medication. EVIDENCE: Care plans are compiled on the basis of the initial assessment prior to admission, on admission and during residency. Care plans were sampled and all had photographs of the service user on the front of the file. Care plans are reviewed on a monthly basis and are drawn up by the home, service user and/or relatives. The inspector examined the file of a recently admitted service user. This evidenced that a care plan had been developed, detailing the service user’s needs and how these are being met. A risk assessment had also been completed. Risk assessments are carried out by senior staff and are reviewed
Gate Lodge G53 S25784 GateLodge V189106 160605 stage4.doc Version 1.30 Page 13 on a regular basis. These cover manual handling and other areas of risk. Each file contains details of all visits to/from the district nurse, GP, hospital and other appointments. Arrangements are in place for service users to be asked whether they wish to see their care plan. The inspector understands that the home has a very good relationship with the local surgery and that the GP visits weekly. The manager has advised that where any healthcare concerns arise, the home will contact the GP immediately. The care plans include a health section, which lists all the healthcare professionals that could be involved with the service users. These include the GP, district nurse, CPN, physiotherapist, dentist, optician or chiropodist. When the service user is seen by the health professional this can then be documented on this chart. Weight charts are used for those service users where there is concern in this area. A section to include action taken in the event of weight changes has been added. The home has an appropriate medication policy and procedures in place. The inspector examined medication records for a number of service users and found these to be up-to-date and accurate. MAR sheets are used; these contain photos of each of the service users. Blister packs are used and kept in a locked cupboard. There is a medication returns book and the pharmacist visits regularly to audit the medication. The last audit took place on 15 February 2005. A recommendation for a separate locked safe for controlled drugs has yet to be actioned. This is made a requirement. There were a number of outstanding issues from the last inspection. The inspector was informed that the service user who took his own medication, and for whom a risk assessment was required, has since died. The registered provider advised that no other service users in the home self-administer their own medication. While the requirement no longer applies, a risk assessment and appropriate precautions for safe monitoring and storage of medication would need to be put in place should there be any wish for self-administration by a service user in the future. A requirement was made at the last announced inspection that “The registered person must ensure that all staff who administers medication undertakes accredited training” The inspector was advised that thirteen of the sixteen staff are registered with NESCOT for accredited training (by distance learning) and have, so far, undertaken an initial induction on 11 and 18 May 2005. Further training is scheduled to take place. The inspector was also advised that all staff have had some medication training from a GP in January, 2005. This training is not, however, accredited and does not meet this requirement. This requirement has been outstanding from the last two inspections and, though partially addressed, must, as a priority, be fully met within the set time-scale (by 1.10.05). Gate Lodge G53 S25784 GateLodge V189106 160605 stage4.doc Version 1.30 Page 14 A requirement in respect of the need for an accurate record to be maintained for all medicines received, administered and leaving the home, has been met. The inspector examined all medication records including MAR sheets and the receipts and returns record. These were in order. A concern regarding an unaccounted prescribed cream in the room of a service user no longer applies. Gate Lodge G53 S25784 GateLodge V189106 160605 stage4.doc Version 1.30 Page 15 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) This section was not assessed on this inspection. EVIDENCE: Gate Lodge G53 S25784 GateLodge V189106 160605 stage4.doc Version 1.30 Page 16 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 an appropriate complaints policy and procedure in place which will give confidence to the service users and their relatives that their complaints will be listened to. Taken seriously and acted upon. The legal rights of service users within the home are being protected and promoted. While the home has appropriate adult protection policies and procedures in place, providing protection for service users. EVIDENCE: Gate Lodge G53 S25784 GateLodge V189106 160605 stage4.doc Version 1.30 Page 17 There is a policy and complaints procedure. A complaints book at the home details the outcome of any complaint and what action (if any) was taken. The complaints procedure is clear and simple and includes the stages and time scales for complaints to be managed. While no complaints have been made since the last announced inspection, the inspector understands that all complaints are taken seriously and would be dealt with promptly and effectively. The procedure states that any complaint will be responded to within twenty-eight days, and that that any complaint can be referred to the CSCI, local office, at any time during the course of investigation. The inspector discussed the need for the home to have a Concerns and Compliments record, and for this to be kept in the reception area where it would be easily accessible for visitors to record their comments. This is made a recommendation. Service users are evidenced to have their legal rights protected. All service users are registered on the electoral roll and a postal vote can be obtained in the event of an election. Service users spoken to by the inspector indicated that they feel secure and safe in the home. No adult protection concerns have been recorded in the last 12 months. There is an Adult Protection and Whistle Blowing Policy in place for staff to reference should the need arise. A requirement made at the last announced inspection for the training of staff to prevent service user’s being harmed or suffering abuse has been met. There is, however, a need for all staff to raise their awareness of Croydon’s local adult protection procedures and to attend Croydon’s multi-agency vulnerable adult protection training. The inspector was advised that seven staff are registered to do this training, four of whom have been given dates for attendance. A requirement is made for all staff to attend this training. The inspector also recommends that the manager or registered person attends an accredited training course on adult protection such as ‘Training for Trainers’. This training can then be cascaded down for the benefit of all staff. Gate Lodge G53 S25784 GateLodge V189106 160605 stage4.doc Version 1.30 Page 18 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 Service users live in a safe, well-maintained environment, with access to safe and comfortable facilities. Risk assessment of the home and individuals are in place for their protection. Service users’ rooms are safe, comfortable and pleasantly decorated, reflecting service users’ personal identities, and being suited to their individual needs. The home presents as clean, pleasant and hygienic. EVIDENCE: Gate Lodge G53 S25784 GateLodge V189106 160605 stage4.doc Version 1.30 Page 19 The home presents as being safe and reasonably well maintained. The home is on two floors, and is accessed by stairs, no passenger lift being available. The home was found to be clean, tidy, and decorated to a reasonable standard. There are, however, a number of health and safety issues which were outstanding from the last inspection. These have mostly been addressed. Hand basins are provided in all rooms and there are two bathrooms both of which were very clean. The inspector noted that there is a disused shower opposite Room 11 which could, subject to an occupational therapist assessment, be renovated and bought back into operation for the benefit of the home’s service users. This is made a recommendation. There are accessible toilets on both floors; these were clean and free from any offensive odours. The inspector was, however, concerned to note that there were no liquid soap or paper towel dispensers in any of the toilets or bathrooms. The installation of these is essential in ensuring proper hygiene, and a requirement applies. The inspector looked at service users bedrooms. These were observed to be comfortable and personalised, reflecting individuals’ identities and meeting their needs. The rooms presented as reasonably well decorated, and were comfortably heated and ventilated. Lockable spaces are provided in bedrooms and curtains are provided for privacy in shared rooms. All rooms have hand basins and window restrictors are in use in the upstairs bedrooms. A requirement from the last inspection, for an audit of all service users’ bedrooms, has been addressed. As a result, some items of worn or broken furniture have been replaced. With the exception of one armchair (which was replaced during the inspection) all the furniture seen appeared to be satisfactory. The registered provider advised that service users and/or their relatives have been consulted regarding the furniture provided in service users’ bedrooms and their wishes recorded. This has identified individual preferences with, for instance, several service users having stated a preference not to sacrifice room space for an additional armchair. The home has spacious communal areas, and these present as pleasant and homely. There is a large lounge is divided into two distinct areas for different uses. The main area is very light and airy and overlooks the garden. Most service users were observed to be sitting here and conversation is encouraged There is a separate smaller area, with less natural light, which is set back, and adjoins the hallway, in which there is a television. None of the service users were sitting in this area during the inspection. A number of service users were spoken to by the inspector. They presented as being very satisfied with their environment and the facilities provided. Gate Lodge G53 S25784 GateLodge V189106 160605 stage4.doc Version 1.30 Page 20 The lounge and dining room overlook a pleasant patio and garden. This is easily accessible and is used by the service users in the summer months. The inspector spoke to one of the service users who used to be a gardener and who indicated that he derives considerable satisfaction from helping out in the garden. This has included creating some lovely displays of potted plants in tubs and along a border. Monthly checks by the management team identify any Health and Safety issues. The home has complied with a requirement from the last announced inspection for a maintenance and development programme, regarding the renewal of the fabric and decoration of the home, to be drawn up. This lists short, medium and long-term plans. It has previously been noted that some of the carpets notably in the downstairs hallway, require renewal. Some bedrooms and communal areas also require some decoration. Another requirement from the last inspection related to fire safety. The inspector was advised that other items of furniture and furnishings, which do not meet current fire safety requirements, have been identified in an inventory and the items replaced. The responsible person must evidence the fire safety assessment, and the results of this inventory, a copy of which must be forwarded to the CSCI. A requirement from the last four inspections, relating to the need for all radiators to be covered with “cool to touch units”, has finally been fully met, with the remaining work having been completed on 16 January 2005, thus meeting the final time-scale set. Central heating can be controlled in each individual room. There is an emergency lighting system. Hot water temperatures are tested daily, records showing that these are within safety limits An outstanding requirement from the last announced inspection, for an assessment of the home by an occupational therapist, has been met, with recommendations having been implemented. These included installing an additional grab rail in one toilet, providing a lockable facility in all service users’ rooms and displaying warning notices on two toilet doors that open outwards on the ground floor. The assessment was completed on 10 July 2004. Stair rails are in place, and rails are fitted along corridors. Also raised toilet seats, commodes and adapted bath chairs are in place. Gate Lodge G53 S25784 GateLodge V189106 160605 stage4.doc Version 1.30 Page 21 The home presented as being clean, tidy and free from offensive odours. Laundry facilities are situated outside in the grounds and are kept locked. There has been redecoration of the laundry walls and relaying of the laundry floor to make these surfaces easier to keep clean. The requirement, which has been outstanding, has now been met within the new timescale given. All COSHH items were observed to be locked away on the day of inspection. An infection control policy is in place and was available for inspection. The registered person advised that all staff have now received formal infection control training. Gate Lodge G53 S25784 GateLodge V189106 160605 stage4.doc Version 1.30 Page 22 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 The home has the numbers and skill mix of staff sufficient to meet the needs presented by the home’s service users, and to ensure their safety. While the home has an appropriate recruitment policy and procedure in place, there have been concerns regarding the completion of staff recruitment checks on this and previous inspections. If the vigilance is not maintained it will result in a loss of confidence that service users can be protected by the home’s recruitment policy. EVIDENCE: The inspector examined the staff rota. This evidenced that there were always three staff on duty, with two waking staff on at night. The home currently has 12 care staff and four ancillary staff, which is sufficient for the number of service users. A requirement from the last inspection related to the need for an action plan detailing how the registered person would meet the minimum ratio of 50 staff trained to NVQ Level 2. None of the current staff team had an NVQ Qualification. The registered provider confirmed that an action plan has been put in place. Two staff are currently studying for the NVQ Level 2 qualification with a further
Gate Lodge G53 S25784 GateLodge V189106 160605 stage4.doc Version 1.30 Page 23 six staff having been placed on a waiting-list with Croydon, and are scheduled to start their training in September 2005. There is an external assessor who will be visiting the home to undertake training with staff. The manager holds an NVQ assessors qualifications D32/33/34 and has indicated that she may be involved in assessing staff herself. Three new staff members have started since the last inspection. The inspector examined the staff files which contained, for the most part the full name, address, date of birth, copies of Birth Certificates and passports (if any), two written references from previous employers, and the dates employment commenced. The inspector noted, however, that one staff member had a CRB in place, dated 10.7.04, which was from a previous employer. The registered provider was informed that portability is not acceptable and that a new CRB check must be obtained prior to any new staff member commencing duties. A requirement is made for a new CRB check for this staff member to be obtained and a copy forwarded to the CSCI, local office. Another staff file only evidenced one suitable reference. The second reference has since been obtained and forwarded to the inspector. The registered provider is reminded that all the checks and information are required as per Schedule 2 of the Regulations and that any new staff appointed by the home may not commence duties until the home is in receipt of a valid CRB check. Any further transgressions in this respect are likely to result in enforcement action being taken. The inspector was informed that since the last inspection training has taken place in a number of key areas. These include Safe Handling of Medication (non-accredited) (27/1/05), Dementia Awareness and Challenging Behaviour (30/3/05), First Aid (22/4/05), and Infection Control (4/5/05). Staff have also previously undertaken training in areas including Fire Prevention, Adult Abuse and Moving and Handling. Training in Food Hygiene is scheduled for 7/7/05. There is, however, a need for accredited medication training (see Standard 9), and statutory adult protection training (see standard 23), which must both be met. The registered person has not, as yet, met the requirement for an annual training plan to be put in place. Given the concerns identified in previous inspections in regard to staff training, this requirement must be met without any further delay. Gate Lodge G53 S25784 GateLodge V189106 160605 stage4.doc Version 1.30 Page 24 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, 36, 37 and 38 The registered manager presented as a fit person to be in charge, with the necessary skills and experience with which to manage the home in the best interests of the home’s service users. The management approach was observed to be conducive to creating an open, relaxed and friendly atmosphere. The home is beginning to develop its quality assurance processes, with service users views being canvassed, and an audit being completed. In order for the service users to feel that the home is being run in their best interests the home needs to develop these processes further. The home is failing to provide regular supervision for staff. This is detrimental to the support and development of staff, and is potentially compromising the protection and safety of service users. Overall the health, safety and welfare of service users and staff are being appropriately promoted and protected. All safety checks and certification are in place. Gate Lodge G53 S25784 GateLodge V189106 160605 stage4.doc Version 1.30 Page 25 EVIDENCE: The manager, Christina Thambirajah, submitted an application to the CSCI in 2004 and is now the home’s registered manager. She is suitably qualified and experienced to run the home to meet its stated purpose, aims and objectives. She has a great deal of management/supervisory experience working with vulnerable people in different settings. She is qualified to level 4 NVQ in Management and holds NVQ assessors qualifications. Since October 2004 she has been assisted in the management of the home by the registered provider’s son, Mr Jason Chellun, who has a background in information technology. Mr Chellun does not have a social care background but is familiar with the home and its’ residents. The inspector understands that Mr Chellum is to register to do an NVQ Level 4 with view to becoming more involved in the running of the home alongside the current manager. Mr Parmaseeven Chellun, the registered provider, confirmed that it is his intention to hand over control of the home in the longer term to his son and that his son would be applying for registered provider status in due course. The management approach was observed to be conducive to creating an open, relaxed and friendly atmosphere, with service users presenting as settled and happy. Many positive comments were made to the inspector regarding the home and the support provided. Staff were engaging well with service users and there was evidence of high morale among the staff members on duty. The home has regular staff meetings and offers regular staff supervision. Regular service user meetings take place every two months. There is a suggestions/minor complaints book situated in the entrance hall for the use of service users, relatives and other visitors. Since the last inspection the home has been developing its quality assurance processes. An annual audit has been completed, the results of which are presented in a report. A development plan still needs to be put in place. A questionnaire has been devised and completed with the home’s service users. The inspector identified a need for questionnaires to be developed for relatives/friends of service users, and one for visiting care managers and other professionals. Requirements apply. The inspector was concerned to find that a requirement from the last inspection for regular supervision of staff has not yet been met. Supervision needs to cover all aspects of practice, philosophy of care in the home and career development needs of the staff as a minimum. In line with standard 36.2 supervision must be provided for every member of staff at least once every two months.
Gate Lodge G53 S25784 GateLodge V189106 160605 stage4.doc Version 1.30 Page 26 All records sampled at this inspection appeared in order and up-to-date. Medication records, service user assessments and care plans all appeared to be comprehensive. General policies and procedures are extensive and are regularly reviewed. The registered provider was unable to provide a copy of the home’s audited accounts for the year 2004/05. These must be obtained and a copy forwarded to the CSCI. The inspector found that the health and safety of service users is being appropriately protected, there being no concerns identified from this inspection. A requirement for all staff to receive formal infection control training has now been fully met. All health and safety maintenance checks were found to be have been completed within the required time-scales. Gate Lodge G53 S25784 GateLodge V189106 160605 stage4.doc Version 1.30 Page 27 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 x 2 3 x x 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x
COMPLAINTS AND PROTECTION 3 3 3 3 3 2 2 2 STAFFING Standard No Score 27 3 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 2 3 3 2 2 x 2 3 3 Gate Lodge G53 S25784 GateLodge V189106 160605 stage4.doc Version 1.30 Page 28 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 OP2 Regulation 5(1)b & c Requirement The Registered Provider must ensure that it is recorded on each service users file that a copy of the homes terms and conditions have been supplied to the service user. A copy of the terms and conditions must be included alongside the local authority three way contract on the service users file. The registered person must ensure that the accredited medication training, which has been accessed, is completed by all staff who administer medication. The registered manager must ensure that all staff attend Croydons one-day Vulnerable Adult protection training. The registered person must ensure that liquid soap and paper towel dispensers are installed in the homes toilets and bathrooms. The registered person must evidence the results of the fire safety assessment of soft furnishings and furniture, to ensure that these fully meet the Timescale for action Time-scale extended to 1.10.05 2. OP9 13(2), 18(1)a Time-scale extended to 1.10.05 3. OP18 13(6) 1.11.05 4. OP26 13(3) & (4)c 1.10.05 5. OP24 16(2)(c) and 23(4)(5) Time-scale extended to 1.08.05 Gate Lodge G53 S25784 GateLodge V189106 160605 stage4.doc Version 1.30 Page 29 6. OP29 19(1)(b) (ii), Sch.2, No.7 7. OP30 18(1)a 8. OP33 24(1)(2)( 3) 24(1)(2)( 3) 9. OP33 10. OP36 18(2) 11. 25(1) &(2)a OP34 current fire safety standards as laid down in the Furniture (Fire Safety) Regulations. The results of this assessment must be sent to the CSCI, local office. The registered person must obtain a new CRB check for a staff member who has a CRB certificate dating from a previous employment. A copy must be forwarded to the CSCI, Croydon office. The responsible person must ensure that a new CRB (Criminal Records Bureau) check is obtained prior to the recruitment of any new care staff. No portability is allowed. The registered person must ensure that a year on year training plan is put in place. This could be developed from annual staff appraisals. (Timescale of 31/03/05 not met) An annual development plan must be put in place to assess whether the aims and objectives of the home have been met. The home must develop surveys with the relatives/friends of service users, and with visiting care managers and professionals, as part of the quality assurance process. The registered person must ensure all staff receives supervision in line with the standard. Supervision must cover all aspects of practice, philosophy of care in the home and career development needs of the staff as a minimum. The registered provider must make available a set of the home’s audited accounts for the year 2004/05. A copy of these must be forwarded to the CSCI. 1.08.05 Time-scale extended to 1.10.05 Time-scale extended to 1.10.05 1.10.05 Time-scale extended to 1.09.05 1.10.05 Gate Lodge G53 S25784 GateLodge V189106 160605 stage4.doc Version 1.30 Page 30 12. 18(1)c OP28 The registered person must ensure that he implements the homes action plan for meeting the minimum ratio of 50 members of staff trained to NVQ level 2 by 2005. 1.10.05 13. 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 OP16 Good Practice Recommendations The inspector recommends that the home maintains a Concerns and Compliments record. This should be kept in the reception area where it is easily accessible for visitors to record their comments. The inspector recommends that the manager or registered person attends an accredited training course on adult protection such as ‘Training for Trainers’ a recognised course which can be cascaded down for the benefit of all staff disused shower opposite Room 11 which could, subject to an occupational therapist assessment, be renovated and bought back into operation for the benefit of the home’s service users. 2. OP18 3. OP21 Gate Lodge G53 S25784 GateLodge V189106 160605 stage4.doc Version 1.30 Page 31 Commission for Social Care Inspection 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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