Inspection on 21/04/06 for Gate Lodge

This inspection was carried out on 21st April 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Gate Lodge 27/04/07

Gate Lodge 19/01/06

Gate Lodge 16/06/05

Gate Lodge 12/04/05

Gate Lodge 04/01/05

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

CARE HOMES FOR OLDER PEOPLE Gate Lodge 1 Upper Woodcote Village Purley Surrey CR8 3HE Lead Inspector Peter Stanley Key Unannounced Inspection 21st April 2006 9:30am 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 Gate Lodge DS0000025784.V288649.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Gate Lodge DS0000025784.V288649.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Gate Lodge Address 1 Upper Woodcote Village Purley Surrey CR8 3HE 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) 020 8668 7286 020 8668 7286 Mr Paramaseeven Chellun Mrs Georgia Chellun Ms Christina Thambirajah Care Home 16 Category(ies) of Dementia - over 65 years of age (16) registration, with number of places Gate Lodge DS0000025784.V288649.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. For people with dementia who are over 65 Date of last inspection 19th January 2006 Brief Description of the Service: Gate Lodge provides residential care for up to 16 service users (65 and over) who have dementia. The home is an attractive detached property located on the green of Upper Woodcote Village within a pleasant residential area; it 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. 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 use of service users. Gate Lodge DS0000025784.V288649.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home provides residential care for 16 elderly service users with dementia. There is currently one vacancy. This unannounced inspection was conducted over one day and involved discussion with the registered provider’s son, Mr Jason Chellun, who is assisting with the management of the home. Mrs Christina Thambirajah, the registered manager, was not present. The inspector spoke with a number of service users, and with staff on duty. The inspector case-tracked one recent admission to the home, and looked at a sample of service users’ care plans. Relevant documentation including staff files, policies and procedures, staff rotas and logs relating to incidents, accidents and complaints, were also examined. The inspector carried out a full inspection of the premises and spoke with staff on duty. Feedback from service users was generally favourable, with many positive comments regarding the care and assistance provided. The inspector also received favourable comments from staff regarding the management of the home and the training and support provided. The inspector noted that of the 17 requirements identified in the previous inspection report, 8 have now been fully met. There are 9 requirements which remain to be met, together with 6 new requirements from this inspection, making 15 in total. There are also 6 recommendations from this inspection, 3 of which are from the previous inspection. What the service does well: Prospective service users are being provided with the relevant information, and opportunity to visit, with which to make an informed choice as to whether the home meets their needs and aspirations. The home is able to demonstrate that it is assessing the needs of prospective service users, and that care management assessments are now being obtained prior to admission. The health care needs of service users are being fully met. Gate Lodge DS0000025784.V288649.R01.S.doc Version 5.1 Page 6 Service users feel that that they are being treated with respect and that their right to privacy is being maintained. The home has an appropriate complaints policy and procedure in place that 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. Service users’ rooms are safe, comfortable and pleasantly decorated, reflecting service users’ personal identities, and being suited to their individual needs. Generally, service users have the specialist equipment they need to maintain their independence. The home presents as clean, pleasant and hygienic. 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. Staff are being provided with the necessary induction and training with which to perform their work duties competently, and to safely meet the needs of service users. The home is now on track for meeting the target of 50 of staff trained to NVQ Level 2. Generally, the health and safety of service users is being appropriately protected and promoted. All health and safety maintenance checks, apart from the home’s hoist, have been completed within the required time-scales. What has improved since the last inspection? Care management assessment information is now being obtained following referral from social services. The service user’s agreement is now being signed and dated by the service user and his/her next of kin or representative. Gate Lodge DS0000025784.V288649.R01.S.doc Version 5.1 Page 7 Service users are having their health, personal care and social needs set out in an individual plan of care, with review taking place on a monthly basis. Personcentred plans, providing a more comprehensive breakdown of service users’ abilities and needs, have now been developed. Service user meetings are now being held on a regular two-monthly basis. Carpeting in the lounge areas is being cleaned on a regular basis. Service users are being protected by the home’s adult protection, policies and training. The awareness of staff has been raised through attending local multiagency adult protection training. The home has demonstrated an improvement in its recruitment practices, but, for service users to be adequately protected, this improvement must be sustained. Adequate staffing is being provided throughout the day and at night. The home is developing its quality assurance processes, with view to evidencing that it is meeting its aims and objectives, and is being run in the best interests of service users. This needs to be consolidated, and a Development Plan put in place. The home is now providing regular two-monthly supervision for staff. The supervision format should, however, be developed so as to reflect more fully the discussion and decisions taken in supervision. The home is on track to achieve a minimum ratio of 50 of staff trained to NVQ Level 2. Criminal records and recruitment checks are now being satisfactorily completed; this improvement must, however, be maintained. What they could do better: While service users can generally be assured that the home will meet their needs, reviews of their care must, where relevant, involve social services care managers or representatives. While service users are being safeguarded by the home’s medication policies and procedures, their protection also requires that all staff complete accredited medication training. Gate Lodge DS0000025784.V288649.R01.S.doc Version 5.1 Page 8 Carpeting in the lounge and dining areas is worn and needs to be replaced. Generally, service users live in a safe, well-maintained environment, with access to safe and comfortable facilities. However, window restrictors must be fitted to ensure the safety of service users in Rooms 4 and 12. There is also a potential risk to safety arising from the failure of the home to ensure regular servicing of the home’s hoist. Service users in some rooms require a lockable space for the safe storage of their money and valuables. 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 DS0000025784.V288649.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Gate Lodge DS0000025784.V288649.R01.S.doc Version 5.1 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 the following standard(s): 1, 3, 4 and 5 Prospective service users are being provided with the relevant information, and opportunity to visit, with which to make an informed choice as to whether the home meets their needs and aspirations. The home is able to demonstrate that it is assessing the needs of prospective service users, and that care management assessments are now being obtained prior to admission. While service users can generally be assured that the home will meet their needs, reviews of their care must, where relevant, involve social services care managers or representatives. EVIDENCE: The home has a Statement of Purpose and Service User Guide that meets the information needs of service users. These documents do not, however, evidence the date when they were last reviewed. A requirement applies. Gate Lodge DS0000025784.V288649.R01.S.doc Version 5.1 Page 11 Since the last inspection the home has admitted one service user. Inspection of the file evidenced a care management assessment, together with risk assessments and a care plan. Examination of a number of service user files indicate that assessments, dependency profiles and risk assessments are being completed by the home. The inspector examined a number of care plans. These are being reviewed on a monthly basis, and the assessed needs of service users are evidenced as being met. The inspector spoke to a wide range of service users; this indicated that there was a high level of satisfaction with the care being provided, with individuals’ differing needs being addressed. This included the needs of a mixed race woman who was satisfied that her specific care and cultural needs were being met. One service user has, however, sustained a number of recent falls and requires referral to an occupational therapist for assessment of her mobility and individual needs. A requirement applies. While, generally, the home is evidenced to be holding care reviews for service users, and a recently admitted service user is not yet due for review, reviews are not involving care managers or representatives from social services. One service user at the home has still not had a review. A requirement applies. Prospective service users, their friends and relatives have the opportunity to visit the home, and meet service users and staff, prior to any decision regarding an admission being taken. Gate Lodge DS0000025784.V288649.R01.S.doc Version 5.1 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 the following standard(s): 7, 8, 9 and 10 Service users are having their health, personal care and social needs set out in an individual plan of care, with review taking place on a monthly basis. Personcentred plans, providing a more comprehensive breakdown of abilities and needs, have now been developed. The health care needs of service users are being fully met. While service users are being safeguarded by the home’s medication policies and procedures, their protection also requires that all staff complete accredited medication training. Service users feel that that they are being treated with respect and that their right to privacy is being maintained. EVIDENCE: Gate Lodge DS0000025784.V288649.R01.S.doc Version 5.1 Page 13 The inspector examined a number of service users’ care plans, these having been compiled on the basis of initial assessment and periodic review. Care plans are being reviewed on a monthly basis and involve discussion with the service user and his/her relatives/representatives. Following a requirement from the previous inspection the home has developed person-centred care plans, which are providing a more person-centred and detailed breakdown of the service user’s care needs, wishes and preferences. The health care needs of service users are generally evidenced as being well met. Feedback from service users, and examination of care notes, indicated that there is good follow up of any health concerns and that health care needs are generally being well met. Care plans include a health section that lists all health care professionals who are involved; this includes GPs (general practitioners), CPNs (community psychiatric nurses) and District Nurses, together with dentists, opticians and chiropodists. The home enjoys a good relationship with the local GP surgery, and a doctor visits on a regular weekly basis. Weight charts are used for those service users where there are concerns about weight. The home has an appropriate medication policy and procedures in place. Medication records were examined and found to be accurate, up-to-date and well-maintained. MAR sheets include photos of the service users, with blister packs being used and kept in a locked cupboard. No service users are currently taking their own medication. There is a medication returns book and the pharmacist visits regularly to audit the medication. This was last audited on 10/2/06. Controlled medication (Diazepan) is currently being used by one service user, this having been recently reviewed by the GP, and being securely stored in a separate locked container within the locked cupboard. Following a long-standing requirement, the home has been gradually extending accredited medication training to care staff. The inspector was advised that 9 staff have so far completed this training, and 5 others (including the registered provider’s son) are currently undertaking this with NESCOT (NorthEast Surrey College of Technology). However, certificates to evidence this training have only been received for 2 staff so far; these must be obtained for all staff completing this training. The requirement remains to be fully met. The inspector spoke to a wide range of service users and again received positive feedback regarding their privacy and dignity being respected within the home. Staff on duty were observed to be interacting with service users in a caring and respectful manner, and staff were observed to knock on service users’ doors before receiving permission to enter their rooms. Gate Lodge DS0000025784.V288649.R01.S.doc Version 5.1 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Not assessed. All standards assessed as met on last inspection. Gate Lodge DS0000025784.V288649.R01.S.doc Version 5.1 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 and 18 The home has an appropriate complaints policy and procedure in place that 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. Service users are being protected by the home’s adult protection, policies and training. The awareness of staff has been raised through attending local multiagency adult protection training. EVIDENCE: Gate Lodge DS0000025784.V288649.R01.S.doc Version 5.1 Page 16 The home has an appropriate complaints policy and 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 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 has previously recommended that the home has a Concerns and Compliments record, and that this is kept in the reception area where it iseasily accessible for visitors to record their comments. This has now been implemented. 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. No adult protection concerns have been identified since the last inspection or within the last 12 months. The home has an Adult Protection and Whistle Blowing Policy in place for staff to reference should the need arise. The inspector spoke to a number of service users. Feedback indicated that they feel secure and safe in the home. All but two staff have now attended Croydon’s multi-agency vulnerable adult protection training. The inspector was advised that two new staff members have applied for places. The inspector 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 DS0000025784.V288649.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 to 26 Generally, service users live in a safe, well-maintained environment, with access to safe and comfortable facilities. However, window restrictors must be fitted to ensure the safety of service users in Rooms 4 and 12. There is also a potential risk to safety arising from the failure of the home to ensure regular servicing of the home’s hoist. Service users’ rooms are safe, comfortable and pleasantly decorated, reflecting service users’ personal identities, and being suited to their individual needs. Generally, service users have the specialist equipment they need to maintain their independence. Service users in some rooms require a lockable space for the safe storage of their money and valuables. The home presents as clean, pleasant and hygienic. Gate Lodge DS0000025784.V288649.R01.S.doc Version 5.1 Page 18 EVIDENCE: Gate Lodge DS0000025784.V288649.R01.S.doc Version 5.1 Page 19 The premises were inspected. Since last year, a double bedroom and the bathroom on the first floor have been redecorated, together with recent redecoration in the main lounge. Carpeting in the lounge area is now being cleaned on a four-weekly basis so as to prevent the recurrence of any unpleasant odours. 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 and hygienic, tidy, and decorated to a reasonable standard, and generally free of any unpleasant odours. The inspector was advised that an extension to the home is being planned which would involve the installation of a lift and an increase in the overall number of service users. Hand basins are provided in all rooms and there are two bathrooms both of which were very clean. The inspector has previously 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. There are, however, no plans to do so at present. There are accessible toilets on both floors; these were clean and free from any offensive odours. The home has spacious communal areas, and these present as pleasant and homely. There is a large lounge, which 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. The home has a maintenance and development programme, regarding the renewal of the fabric and decoration of the home. This lists short, medium and long-term plans. It has previously been noted that some of the carpets, notably in the lounge and dining areas, require renewal. Mr Jason Chellun requested that the carpeting be replaced once the new extension has been completed. The inspector was advised that this is scheduled to be completed within the next 12 months. The inspector agreed an extension to the time-scale to allow for this. The inspector spoke to a number of service users who were sitting in the main lounge during the inspection. They presented as being settled and very satisfied with their environment and with the facilities provided. All radiators in the home have been covered with “cool to touch units”. Central heating can be controlled in each individual room. There is an emergency lighting system. Hot water temperatures are being tested weekly. Gate Lodge DS0000025784.V288649.R01.S.doc Version 5.1 Page 20 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. Curtains are provided for privacy in shared rooms. All rooms have hand basins. There are two double bedrooms (Rooms 12 and 15). The inspector was advised by Mr Chellun that the services users concerned are happy with sharing a bedroom, and that there have been no problems in this regard. Lockable spaces are provided in most but not all bedrooms (none being present in Rooms 8, 10, and 15, and only one in the double Room 12); a requirement applies. While window restrictors are in use in most upstairs bedrooms, restrictors to windows were not found to have been fitted in Rooms 4 and 12; a requirement applies. 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. None of the service users were accessing the garden on the day of inspection. Monthly checks by the management team identify any health and safety concerns. Risk assessment of the home and individuals are in place for their protection. The home was last assessed by an occupational therapist on 10 July 2004, and recommendations for aids and adaptations implemented. Stair rails are in place, and rails are fitted along corridors. Grab rails in toilets, raised toilet seats, commodes and adapted bath chairs are in place. Generally, the home presented as providing the necessary specialist equipment required to safety meet service users’ needs and maximise their independence. The inspector was, however, concerned to find that the home’s hoist has not been recently serviced; a requirement applies. Gate Lodge DS0000025784.V288649.R01.S.doc Version 5.1 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 to 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. The home has demonstrated an improvement in its recruitment practices, but, for service users to be adequately protected, this improvement must be sustained. Staff are being provided with the necessary induction and training with which to perform their work duties competently, and to safely meet the needs of service users. The home is now on track for meeting the target of 50 of staff trained to NVQ Level 2. EVIDENCE: The inspector examined the staff rota. This evidenced that there were two staff on duty, plus the person in charge, during the day with two waking staff on at night. The home currently has 12 care staff and three ancillary staff, which is sufficient for the number of service users. The inspector spoke to a wide range of service users. Feedback indicated that service users felt able to rely on staff to meet their needs and to provide appropriate assistance when required. No concerns were expressed. Gate Lodge DS0000025784.V288649.R01.S.doc Version 5.1 Page 22 One new staff member has started since the last inspection. The inspector examined the staff file and found that all recruitment checks (including a CRB) have been satisfactorily completed. A recommendation for the home’s providers to provide a checklist of all the recruitment checks required still needs to be developed; this must include the dates when checks have been completed. Following previous concerns relating to CRB (Criminal Records Bureau) checks not having been obtained, the inspector has advised the registered provider that there must be no further employment of any person at the home without a CRB and POVA check, unless there has been a written request to the CSCI (addressing all the relevant criteria) and agreement given (in writing) by the inspector. Staff are evidenced to be provided with the necessary induction and training with which to perform their work duties competently, and to safely meet the needs of service users. An induction and training programme is in place and this is updated regularly. The home is now on track for meeting the target of 50 of staff trained to NVQ Level 2. The inspector spoke to staff on duty and received positive feedback regarding the supervision, support and training opportunities provided. There has been a programme of ongoing training which has involved staff in studying for their NVQs (National Vocational Qualifications), and attending training in dementia awareness, first aid, food hygiene, infection control, manual handling, accredited medication and adult abuse training. Training in challenging behaviour still, however, needs to take place; a recommendation applies. Mr Chellun advised that, since 5/12/05 all staff have been undertaking their NVQ 2 training and that 3 staff (including both deputy managers) are studying for their NVQ3. 5 staff are currently undertaking dementia training with NESCOT (North-East Surrey College of Technology), while 5 staff are scheduled (on 8/5/06) to do manual handling training. First aid and food hygiene training has been completed by all but 2 staff, while 3 staff have still to complete infection control training. Gate Lodge DS0000025784.V288649.R01.S.doc Version 5.1 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 36, 37 and 38 The home is developing its quality assurance processes, with view to evidencing that it is meeting its aims and objectives, and is being run in the best interests of service users. This needs to be consolidated, and a Development Plan put in place. The home is now providing regular two-monthly supervision for staff. The supervision format should, however, be developed so as to reflect more fully the discussion and decisions taken in supervision. Generally, the health and safety of service users is being appropriately protected and promoted. All health and safety maintenance checks, apart from the home’s hoist, have been completed within the required time-scales. EVIDENCE: Gate Lodge DS0000025784.V288649.R01.S.doc Version 5.1 Page 24 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 questionnaire has been devised and completed with the home’s service users, and a questionnaire has been developed for the relatives and friends of service users. A questionnaire has now also been developed for visiting professionals and care managers. There is an unmet requirement for a development plan to be put into place; the inspector was advised that this is due to be met within the existing prescribed time-scale. In accordance with Section 26 of the Care Homes Regulations, the registered provider must complete an unannounced Section 26 visit at least once a month, to inspect the premises and interview service users and staff. A written report must be completed, and a copy forwarded to the CSCI. A requirement applies. The inspector examined staff supervision notes and was pleased to find that staff are now receiving supervision on a 2-monthly basis; this represents a considerable improvement, and has been in part facilitated by the delegation of some supervision to a deputy manager. This will, however, be closely monitored on future inspections to ensure that this frequency is maintained. Supervision must, however, be evidenced to cover all aspects of practice, philosophy of care, training and personal/career development. While a new supervision format has been put in place, this needs to be further developed so as to provide an agenda and sufficient space for the recording of issues discussed. Gate Lodge DS0000025784.V288649.R01.S.doc Version 5.1 Page 25 All records sampled at this inspection presented as well maintained and up-todate. Medication records, service user assessments, care plans and reviews, and staff records were examined. General policies and procedures are extensive and are regularly reviewed on an annual basis. The inspector found that, generally, the health and safety of service users is being appropriately protected. There were, however, some concerns. Most concerning was the failure of the home to have ensured regular servicing of the home’s hoist. Window restrictors must also be fitted to all windows in Rooms 4 and 12, there being a potential risk to service users. The registered provider was evidenced to have completed a Health and Safety inventory on 21/3/06. The registered provider must, however, compile a Health and Safety Risk Assessment format for the home, and complete this accordingly. Requirements apply. All health and safety maintenance checks were found to be have been completed within the required time-scales. A fire risk assessment was completed on 24/2/06 and a fire safety inspection carried out on 9/11/05. This included inspection of fire alarms and equipment, emergency lighting and the emergency call system. Fire safety training for staff recently took place on 6/4/06. Hot water temperature checks are being completed weekly, together with weekly fridge/freezer checks. Gate Lodge DS0000025784.V288649.R01.S.doc Version 5.1 Page 26 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 2 X 2 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 3 2 3 2 3 2 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X X 2 3 2 Gate Lodge DS0000025784.V288649.R01.S.doc Version 5.1 Page 27 Are there any outstanding requirements from the last inspection? Yes 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 OP3 Regulation 14(2)(a) & (b) Requirement The registered provider must ensure that care reviews are held for all service users, following their admission to the home. Where the admission has followed a care management referral, the review must involve the respective health or social services representative. A review for one recent admission must be arranged without any further delay. This must be evidenced at the next inspection. Previous time-scale not met. 2 OP4 14(4)(a) & (c) A service user who has sustained 30/06/06 a number of falls must be referred to an Occupational Therapist for assessment of her mobility and individual needs. A copy of the O.T. report must be evidenced, and any recommendations (including any aids or adaptations) must be implemented. Gate Lodge DS0000025784.V288649.R01.S.doc Version 5.1 Page 28 Timescale for action 31/05/06 3 OP7 15(1) & (2) The home must develop a more detailed, person-centred, service user plan. This must evidence the full involvement of the service user and his/her representative, and provide a detailed breakdown of the person’s physical and mental health care needs, personal care needs, self-caring and independent abilities, and their social and emotional needs. This must evidence the agreement of the service user and his/her representative, and be signed and dated. The registered person must ensure that the accredited medication training, which has been accessed, is completed by all care staff who administer medication. This training must be evidenced with the relevant certification. Previous time-scale not met. 31/07/06 4 OP9 13(2), 18(1)(a) 31/10/06 5 OP22 23(2)(n) The home must have an up-todate assessment from an Occupational Therapist. This must assess the suitability of the home in meeting the needs of the home’s service users. A copy of the O.T. assessment report must be evidenced and any recommendations (including any aids or adaptations) must be implemented. 31/10/06 6 OP24 12(4)(a) 23(2)(m) The registered provider must ensure that each service user has a lockable storage facility in his/her room for the safe storage of medication, money and DS0000025784.V288649.R01.S.doc 30/09/06 Gate Lodge Version 5.1 Page 29 valuables. 7 OP26 13(4)(a) & (c) The registered provider must ensure that the carpeting in the lounge and dining areas (which is becoming worn and unhygienic) is replaced with new carpeting. This must then be maintained to a satisfactory standard. Previous time-scale not met. 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. (The home is on track for meeting this requirement). Previous time-scale not met. The registered provider must complete an unannounced Section 26 visit at least once a month and complete a written report (see reg.26(4) (a,b & c). A copy of the monthly report must be forwarded to the CSCI. 10 OP33 24(1)(2)( 3) An annual development plan must be put in place to assess whether the aims and objectives of the home have been met. Regular two-monthly supervision must aim to cover all aspects of practice, the philosophy of care in the home, and the training and career development needs of staff. (See also recommendation relating to supervision). The Statement of Purpose and the Service User Guide must evidence the date when they were last reviewed, and be DS0000025784.V288649.R01.S.doc 21/04/06 8 OP28 18(1)c 31/10/06 9 OP33 26(1)(3)( 4) & (5) 31/05/06 30/04/06 11 OP36 18(2) 31/05/06 12 OP1 6(a) & (b) 31/05/06 Gate Lodge Version 5.1 Page 30 signed by the responsible person who has undertaken the review. 13 OP38 13(4)(a) & (c) 13(4)(a) & (c) Window restrictors must be fitted 31/07/06 to all windows in Rooms 4 and 12. The registered provider must ensure that the home’s hoist is serviced without delay, and thenceforth on a regular 3 monthly basis. The registered provider must put in place an appropriate Health and Safety Risk Assessment format for the home, and complete this accordingly. 31/05/06 14 OP38 15 OP38 13(4)(a), (b) & (c) 30/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP29 Good Practice Recommendations The inspector recommends that the home’s providers ensure that a checklist of all the documentation and checks required (as required by Schedule 2) be maintained on the front of each staff file. The inspector recommends that staff undertake training in working with service users who present challenging behaviour. The inspector recommends that both deputy managers receive supervision and appraisal training, and that there is some delegation of the supervisory workload to both deputy managers. The inspector recommends that a more detailed DS0000025784.V288649.R01.S.doc Version 5.1 Page 31 2 OP30 3 OP36 4 OP36 Gate Lodge supervision format is developed so as to provide a more structured and detailed record of supervision. This should include an agenda of issues identified for discussion (including issues b/f from the previous supervision), and then (in separate columns) details of each issue discussed, the discussion points covered, and the actions/decisions agreed. Supervision notes should be signed and dated by both the supervisor and supervisee. 5 OP38 The inspector recommends that a Health and Safety maintenance checklist is maintained at the front of the Health and Safety file. This should detail the dates when health and safety checks were last completed and the dates when they next become due. The inspector recommends that the manager or registered person attends an accredited training course on adult protection such as ‘Training for Trainers’. 6 OP18 Gate Lodge DS0000025784.V288649.R01.S.doc Version 5.1 Page 32 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 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 © 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 Gate Lodge DS0000025784.V288649.R01.S.doc Version 5.1 Page 33 - 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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