Inspection on 18/04/06 for George Mason Lodge

This inspection was carried out on 18th April 2006.

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

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

Other inspections for this house

George Mason Lodge 27/10/05

George Mason Lodge 31/05/05

George Mason Lodge 26/01/05

George Mason Lodge 19/08/04

George Mason Lodge 16/03/04

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

CARE HOMES FOR OLDER PEOPLE George Mason Lodge Chelmsford Road Leytonstone London E11 1BS Lead Inspector Rob Cole Unannounced Inspection 18th April 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address George Mason Lodge DS0000036539.V289465.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. George Mason Lodge DS0000036539.V289465.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service George Mason Lodge Address Chelmsford Road Leytonstone London E11 1BS 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 8496 3000 London Borough of Waltham Forest Mr Peter Kenneth Stanley Care Home 41 Category(ies) of Dementia (17), Dementia - over 65 years of age registration, with number (17), Mental disorder, excluding learning of places disability or dementia (8), Mental Disorder, excluding learning disability or dementia - over 65 years of age (8), Old age, not falling within any other category (25) George Mason Lodge DS0000036539.V289465.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The 9 bedded intermediate care unit can accommodate OP, DE(E) and DE 60 years. 27th October 2005 Date of last inspection Brief Description of the Service: George Mason Lodge is a registered care home for elders situated in the Leytonstone area of the London Borough of Waltham Forest. The home is run by the Local Authority. The home also includes the provision of a nine bedded intermediate care facility that was set up in March 2003 to provide a period of short term rehabilitation, using specialist occupational and physiotherapy interventions to a similar group pf service users. It is a joint health and social services undertaking with the overall managerial responsibility vested in the registered care manager. George Mason Lodge DS0000036539.V289465.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 18/4/06 and as unannounced. The inspector had the opportunity of speaking with service users, their relatives, staff and the homes deputy manager was present throughout the inspection. Overall the inspector was satisfied that this is a well run home. Service users spoken to informed the inspector that they are happy with the level of care and support provided. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. George Mason Lodge DS0000036539.V289465.R01.S.doc Version 5.1 Page 6 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 George Mason Lodge DS0000036539.V289465.R01.S.doc Version 5.1 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 and 6 The inspector was satisfied that service users are provided with sufficient information about the home to make an informed choice as to move in or not. This information is provided through written documentation and the chance to visit the home. EVIDENCE: The home has a Statement of Purpose and Service User Guide in place. The Statement includes details of the organisation and management, the aims and objectives of the home and a section on the homes Intermediate Care Unit (ICU). The home has recently been registered to provide care to service users with dementia, and although the Statement includes a section on this, it also states that the home is not able to provide care to service users with dementia. It is required that the information in the Statement is consistent and accurate. Further, the Statement is not dated, nor is there any indication of when it is next due to be reviewed. All of this must be addressed. The Service User Guide includes details of the physical environment and the homes complaints procedure. All service users are provided with a statement of terms and conditions, which includes fees payable and what they cover, George Mason Lodge DS0000036539.V289465.R01.S.doc Version 5.1 Page 8 accommodation provided and the care and services which the home offers. These statements are signed either by the service user, or their representative as appropriate. The home has copies of community care assessments carried out by social services for service users, and the inspector was pleased to note that since the previous inspection the home now carries out its own pre admission assessments for service users. Assessments cover needs associated with medication, mobility and social and leisure needs. The home has an admissions procedure. This states that prospective service users will be given the opportunity of visiting the home prior to making any decision as to move in or not. Service users will initially move in on a six week trial basis, after which a placement review meeting will be held, attended by the service user, their family, social worker and staff from the home. Service users spoken to confirmed to the inspector that they had indeed had the opportunity of visiting the home before moving in. Through observation and discussion there was evidence that the home is able to meet the collective and individual needs of service users. Staff demonstrated a good understanding of individual service users needs, and were seen to support them in a sensitive manner. Staff showed a good ability to communicate with service users, some of whom have complex communication needs. The home has a designated nine bed ICU Unit. The Unit was well maintained and decorated to a high standard, and all service users have their own ensuite bedroom. The home also has a therapy room for service users in this unit. The unit is staffed by a therapy team consisting of physiotherapists, rehab assistants and occupational therapists and care staff. Service users in the ICU unit said they were generally satisfied with the level of care and support provided. George Mason Lodge DS0000036539.V289465.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 and 11 The inspector was satisfied that the home is able to meet the personal and health care needs of service users. Medications are stored, recorded and administered appropriately, and care planning is of a good standard. EVIDENCE: All service users have care plans in place. Plans are in plain English, and drawn up with the involvement of service users, their relatives and staff from the home. Plans covered medical, mobility, health and social and leisure needs. There was evidence that plans are reviewed monthly. Daily logs are maintained, and these are linked to care plans. The home has recently introduced a “Life History” for service users. These are drawn up with the involvement of the service user, their relatives and staff from the home. The inspector considered these to be of a good standard, and a useful tool in understanding service users needs and helping staff to meet those needs. Service users also have risk assessments in place. These are clear and comprehensive, and based around the individual service user. For example, it has been identified that one service user is prone to wandering outside the building, a risk assessment is in place around this, including strategies to manage and reduce the risk. George Mason Lodge DS0000036539.V289465.R01.S.doc Version 5.1 Page 10 All service users are registered with a GP, staff informed the inspector that service users are able to retain the GP they had prior to admission where practical. The home keeps records of medial appointments, these indicated that service users have access to health care professionals as appropriate. However, these records are kept in several different places, for example some appointments are recorded in service users daily logs, some in the homes diary, while there are separate books for recording dentists and opticians appointments, thus making it difficult to track and monitor the health care received by service users. The home has devised a form for recording all medical appointments, including any follow up action necessary, however, this has not been implemented, and this is required. The home has a comprehensive medication policy in place, and all staff undertake training before they are able to administer mediations. The homes supplying pharmacist visits the home monthly to inspect the storing, administration and recording of medications. The home keeps records of medications entering the home and of those that are returned to the pharmacist. All medications are administered by two staff to help reduce the risk of errors occurring. Medications are stored in locked cabinets within each unit of the home. Medication Administration Record charts are maintained, these appeared to be accurate and up to date. Through observation and discussion there was evidence that service users privacy and dignity is respected. The laundry system helps ensure that service users only wear their own clothes, and all were appropriately dressed on the day of inspection. Screening is provided in shared bedrooms, and staff were seen to knock and wait before entering bedrooms. The home seeks and records the wishes of service users on arrangements to be made in the event of their death, and staff informed the inspector that service users are able to remain in the home with a terminal illness, as long as the home can meet their medical needs. George Mason Lodge DS0000036539.V289465.R01.S.doc Version 5.1 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 the following standard(s): 12,13,14 and 15 The inspector was satisfied that service users are supported to live valued and fulfilling lives. Appropriate social and leisure activities are provided, and food was of a high standard. EVIDENCE: Service users have access to a variety of activities. On the day of inspection service users were observed to be playing various games, e.g. cards and dominoes, they also had access to TV, video and music. The home has a weekly activities programme, which was advertised by a poster on display, which included bingo and coffee mornings. The home arranges for professional entertainers to visit the home once a month to perform shows. Day rips are also arranged, for example to Southend. The home arranges for mass to be taken once a fortnight. Service users have a large degree of control over their daily lives, for example when to get up and what to wear. Service users have access to advocacy services, and can see visitors in private and at a time of their choosing. They are able to bring their own possessions to the home when they move in, and have access to their confidential records as appropriate. George Mason Lodge DS0000036539.V289465.R01.S.doc Version 5.1 Page 12 Records are maintained of menus, these indicated that service users are offered a varied, balanced and nutritious diet. On the day of inspection there was a choice of chicken stew of savoury mince, both served with fresh vegetables, and both appeared appetizing and healthy. Fresh fruit was also available, and service users were observed to be offered drinks and snacks throughout the day. Service users spoken to informed the inspector that food was of a good standard, and served in sufficient quantities. The kitchen was clean and tidy, and food was stored appropriately. Records are kept of fridge and freezer temperatures. Where necessary, support with eating was provided in a sensitive manner, and mealtimes were observed to be relaxed and unhurried. George Mason Lodge DS0000036539.V289465.R01.S.doc Version 5.1 Page 13 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 It is the view of the inspector that the home has taken appropriate steps to help ensure the safety and protection of service users. Polices and procedures are in place around complaints and adult protection, and staff have undertaken suitable training. EVIDENCE: The home has a complaints log, this indicated that complaints are appropriately investigated and recorded, although the inspector was informed that the home has not received ay complaints since the last inspection. The home also has a complaints procedure, all service users are given their own copy, and an abbreviated version was on display within the home. Service users demonstrated a good understanding of whom they could complaint to if they so wished. There was evidence that service users legal rights are protected, for example all service users are on the electoral register, and service users spoken to confirmed that they are able to vote in elections. The home is run by the Local Authority, and has a copy of the Local Authorities adult protection procedures. All of the staff team have undertaken training in adult protection issues. Staff spoken to demonstrated a good understanding of the issues around adult protection. George Mason Lodge DS0000036539.V289465.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25 and 26 The inspector believes that physically the home is suitable to meet its stated purpose. Service users have adequate communal and private space, and the home was generally well maintained and domestic in character. EVIDENCE: The home is situated in the Leytonstone area of the London Borough of Waltham Forest, close to shops, transport networks and other local amenities. The home is built over three floors; service users are accommodated on all three floors. The home was generally well maintained. At the previous inspection it was found that some of the window frames were rotting in service users bedrooms, these have all now been replaced. The home provides adequate communal sitting and recreational space for service users, consisting of sitting rooms, dinning areas and a well maintained garden with appropriate garden furniture. The home has a designated smoking area. The home was generally clean and tidy, and furniture was well maintained and domestic in character. The dementia and mental health units have been decorated since the last inspection. George Mason Lodge DS0000036539.V289465.R01.S.doc Version 5.1 Page 15 The home has suitable bathing and toilet facilities to meet service users needs. These are situated throughout the home with locks fitted. Many of the baths are adapted to make them accessible to service users. On the day of inspection bathrooms and toilets were clean, tidy and free from offensive odour. All bedrooms in the ICU are ensuite. The inspector checked several service users bedrooms, all of which were clean, tidy and free from offensive odours. Bedrooms were decorated to service users personal tastes, with family photographs much in evidence. Rooms had adequate furniture, including wardrobes and chest of draws. Bedding, carpets and curtains were well maintained and domestic in character. Bedrooms meet National Minimum Standards on size requirements. All bedrooms have central heating, and radiators all have appropriate protective covering. Lighting in rooms is domestic in character, and there is emergency lighting situated throughout the home. Bedrooms have adequate natural light and ventilation. The home has a policy in place on infection control. There are sluice rooms on all floors, and used continence products are disposed of in a macerator. However, on the day of inspection the sluice room on the dementia unit was found to be unlocked, and containing used continence products, and it is required that this room is kept locked. Protective clothing such as gloves and aprons are available for staff. The home employs designated laundry staff, and the laundry room was well maintained, with an impermeable floor. Hand washing facilities are situated within the laundry room, and throughout the home. George Mason Lodge DS0000036539.V289465.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 The inspector was satisfied that the home is staffed in sufficient numbers to meet service users needs, and that staff are competent to carry out their duties. However, the home must ensure that all appropriate pre employment checks are carried out on all staff. EVIDENCE: The home provides 24-hour support, including an emergency on-call procedure. As well as care staff, the home employs therapy staff, administrative staff, laundry staff, cleaning staff and cooking staff. There was a staffing rota on display within the home, this accurately reflected the actual staffing situation on the day of inspection. All staff are provided with a copy of their job description, and staff spoken to demonstrated a good understanding of their roles and responsibilities. All staff employed by the home are 21years old or above. The home has polices in place on equal opportunities and recruitment and selection. Staff employment records are not kept at the home, but are stored centrally by the Local Authority. At a previous inspection the home had been issued with a sheet to record and verify what pre employment checks had been carried out on staff. However, these had not been completed, and the home was unable to evidence that all necessary pre employment checks had been carried out on staff. It is therefore a requirement that the home carries out all pre employment checks for staff in line with Schedule 2 of the Care Homes Regulations 2001. George Mason Lodge DS0000036539.V289465.R01.S.doc Version 5.1 Page 17 The home has a structured induction programme for all new staff, this includes service user issued and health and safety. Training is on going for staff, and the inspector was impressed with the level of training provided, especially around mental health issues and dementia. Staff have also received recent training in managing conflict, food hygiene and medication. Five of the care staff currently employed at the home have achieved a relevant care qualification, and the inspector was informed that the other seven are working towards such a qualification. George Mason Lodge DS0000036539.V289465.R01.S.doc Version 5.1 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,36,37 and 38 The inspector was satisfied that the manager is sufficiently experienced to carry out their duties, and that George Mason Lodge is generally a well run and well managed home. EVIDENCE: The home has a manager, deputy manager and acting senior residential social worker in place. The manager has twenty one years experience of working in residential care, including seventeen years in a managerial capacity. They have a qualification in social work, and NVQ Level 4 in management. Service users spoken to informed the inspector that they found the manager to be approachable and accessible. Care plan reviews, service user meetings and staff meetings all contribute to quality assurance within the home. Copies of previous inspection reports were available to view in the home, and since the previous inspection there was George Mason Lodge DS0000036539.V289465.R01.S.doc Version 5.1 Page 19 evidence that the home now has monthly unannounced Regulation 26 visits. The home issues questionnaires to service users to gain their feedback, and those seen by the inspector evidenced generally positive feedback. Record keeping in the home was of a good standard. Confidential records are stored securely, staff and service users can access their records as appropriate. All staff receive regular formal supervision from one of the three senior staff. Records are kept of supervision, and staff have access to these records. Supervision covers performance, training and service user issues. All staff also receive an annual appraisal. The home has various health and safety policies in place, for instance on infection control and COSHH. Staff undertake statutory health and safety training, including manual handling and first aid. Fire fighting equipment was situated around the home, and was last serviced in June 2005. Fire exits were free from obstruction and clearly signed. Fire alarms are tested weekly, and were last serviced on the 9/9/5. Since the previous inspection the home now has an up to date fire risk assessment in place. The home has had recent gas, PAT and electrical installation safety checks. The home has in date employer’s liability insurance cover. George Mason Lodge DS0000036539.V289465.R01.S.doc Version 5.1 Page 20 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 3 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 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 Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 3 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 3 3 3 X X 3 3 3 George Mason Lodge DS0000036539.V289465.R01.S.doc Version 5.1 Page 21 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 OP8 Regulation 13 Requirement The registered person must ensure that clear, easily accessible and comprehensive records are maintained of all medical appointments, including details of any follow up action necessary. (Timescale 28/2/06 not met) The registered person must ensure that the Statement of Purpose is dated, subject to regular review, and that it accurately reflects the homes categories of registration. The registered person must ensue that all sluice rooms containing clinical waste are kept locked. The registered person must ensure that all required pre employment checks are carried out for all staff in line with Schedule 2 of the Care Homes Regulations 2001. Timescale for action 31/08/06 2. OP1 4 and 6 31/08/06 3. OP26 13 and 23 31/08/06 4. OP29 19 31/08/06 George Mason Lodge DS0000036539.V289465.R01.S.doc Version 5.1 Page 22 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations George Mason Lodge DS0000036539.V289465.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection East London Area Office Gredley House 1-11 Broadway Stratford London E15 4BQ 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 George Mason Lodge DS0000036539.V289465.R01.S.doc Version 5.1 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!