Inspection on 10/06/05 for Gledhow Lodge

This inspection was carried out on 10th June 2005.

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

Gledhow Lodge 04/06/07

Gledhow Lodge 20/06/06

Gledhow Lodge 21/10/05

Gledhow Lodge 13/10/04

Gledhow Lodge 20/05/04

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

CARE HOMES FOR OLDER PEOPLE Gledhow Lodge 51/53 Gledhow Wood Road Leeds West Yorkshire LS8 4DG Lead Inspector Sean Cassidy Unannounced 10 June 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Gledhow Lodge J52 S1454 Gledhow Lodge V232371 100605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Gledhow Lodge Address 51/53 Gledhow Wood Road Leeds LS8 4DG 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) 0113 266 7806 Yorkshire Residential Care Limited Mrs Andrea Atkinson Care home 25 Category(ies) of Dementia - over 65 (25) registration, with number of places Gledhow Lodge J52 S1454 Gledhow Lodge V232371 100605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 13/10/04 Brief Description of the Service: Gledhow Lodge is situated in Oakwood a leafy suburb in the north of Leeds close to the amenities of Roundhay park and the canal gardens and it is only a short bus ride from the city centre. The home is well served by local shops, a library and numerous cafes. This establishment is Georgian grade 2 listed building offering accommodation on two levels.The home is registered to provided specialised dementia care to older people. Gledhow Lodge J52 S1454 Gledhow Lodge V232371 100605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out by two inspectors and lasted a full day. The purpose of this inspection was to ensure the home was operating and being managed to a satisfactory standard for the benefit of the residents. The methods used in this inspection included discussions with service users, visitors and staff, examination of records including service users care plans and staff files, a tour of the home and indirect observation of care practices. The inspectors spoke to several service users and members of staff. A number of documents were examined which included care plans, staff files and training files. What the service does well: What has improved since the last inspection? Activities are being provided to residents outside of the home environment. A new cleaner has been employed so that staff have more time to spend with the residents. Gledhow Lodge J52 S1454 Gledhow Lodge V232371 100605 Stage 4.doc Version 1.30 Page 6 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. Gledhow Lodge J52 S1454 Gledhow Lodge V232371 100605 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Gledhow Lodge J52 S1454 Gledhow Lodge V232371 100605 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,5. The procedure for assisting residents and their families to make an informed choice about moving into the home is good. Residents are appropriately assessed before admission and are offered a trial period. Residents do not receive a written statement of their terms and conditions at the point of admission. EVIDENCE: Residents and relatives said the home provided information that assisted with making their decision to move in. The Statement of Purpose and Service User Guide meet the standard and were available at the time of the inspection. One relative said that the family had visited the home prior to admission and had received a lot of written information about the home. Trial visits are offered to prospective service users. Assessments of residents are carried out prior to a place being offered. The assessment documentation covers all the areas that are highlighted in the standard. A number of omissions were identified within this document, which meant a full assessment of the resident was not being taken. Gledhow Lodge J52 S1454 Gledhow Lodge V232371 100605 Stage 4.doc Version 1.30 Page 9 Contracts and terms of conditions are not provided to residents at the point of admission to the home so residents are unaware of their rights and responsibilities. Gledhow Lodge J52 S1454 Gledhow Lodge V232371 100605 Stage 4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10. The care plans developed for individual residents are concise and informative. However, resident involvement with the development of care plans was inconsistent. The health care needs of residents are not fully met. The health and safety of the residents is compromised by unsafe practices in relation to storage and administration of medicines. Privacy and dignity of the residents was respected but improvements could be made. EVIDENCE: Care plans were in place for all those resident care files that were examined. Care plans were developed when a need was identified in the assessment. The care plans were reviewed on a monthly basis. Not all care plans or risk assessments contained evidence that the resident or their representative have been involved with the process. Care files recorded when a Health Professional had attended a resident. Risk assessments were carried out for nutrition and falls. Regular weights were Gledhow Lodge J52 S1454 Gledhow Lodge V232371 100605 Stage 4.doc Version 1.30 Page 11 seen in all care files examined. It is important that the home ensures that when weight recordings show significant weight gain or loss then the appropriate health professional is contacted. There are problems with residents experiencing incontinence problems which are not being appropriately dealt with. Closer links with the continence nurse advisers in the community is needed. Medication storage and administration practice did not meet with the Royal Pharmaceutical Guidelines and placed residents at risk. Medications were being dispensed secondarily and the medication cupboard was not locked. Staff were seen to treat residents with courtesy and respect. Relatives spoken to agreed felt staff were very supportive with their relatives and treated them with respect. Many of the residents’ wardrobes and drawers were found to contain clothes with no labels on. The laundry room had baskets that contained clothing belonging to each individual resident. Most baskets contained clothes that were unlabelled. The person working in the laundry at the time was sure that she knew whose clothes belonged to whom. This system does not properly ensure residents wear their own clothes. Gledhow Lodge J52 S1454 Gledhow Lodge V232371 100605 Stage 4.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14,15. The home is attempting to ensure the social, cultural, religious and recreational needs of the service users are being met. Relationships with family and friends are maintained whenever possible. The menu for the home appears appealing and well balanced. There are areas that could be improved to ensure the residents’ other needs are appropriately met. EVIDENCE: The resident assessments record their hobbies and interests but not all care plans seen showed how the home ensures that they will assist the resident to continue with these interests. The home has now started to provide planned days out for residents. The first was to Roundhay Park and this was thoroughly enjoyed. Another is planned for the near future in Knaresborough. All residents have now been registered with the Access Bus that will assist future planned outings. Residents and relatives spoken to confirmed that the provision of regular activities was consistent within the home. Representatives of the Catholic and Protestant faiths provide religious services within the home twice a month alternatively. There were no other faiths represented in the home. One visitor commented that there were lots of parties, mainly for birthdays. Gledhow Lodge J52 S1454 Gledhow Lodge V232371 100605 Stage 4.doc Version 1.30 Page 13 They also said that the home had gone to a lot of trouble at Christmas to make it nice for everyone. It was identified that the majority of residents are out of bed, dressed and washed, before the morning staff come on duty. No records were seen in the care plan to show that there was agreement obtained from the resident, which implies this practice is for the benefit of the staff as opposed to the residents. This should be reviewed. A number of relatives spoken to said that the visiting times were very relaxed and they always felt welcomed when they entered the home. The home kept them up to date with any changes with their family members well being. The lunchtime meal looked appealing and seemed to be enjoyed by the residents. A choice of meal is offered at lunch times and there is a hot option in the evening as well. The cook is aware of the likes and dislikes of residents, which she incorporates into the meal planning. The cook bakes pastries and buns regularly which were enjoyed by residents. One resident said that she enjoyed oranges and pears but hasn’t had any as yet. The home only purchases bananas. Gledhow Lodge J52 S1454 Gledhow Lodge V232371 100605 Stage 4.doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18. Residents and relatives are assured that their complaints will be taken seriously and investigated appropriately. Residents could be more protected by the provision of recognised Adult Protection training to all staff. EVIDENCE: The complaints procedure is well displayed throughout the home and most resident rooms have a copy on the wall. Those spoken said they knew how and who to complain to if the need arose. Five separate complaints have been made regarding the care provided within the home since the last inspection. Theses were investigated by the home and were found to be unsubstantiated. The home investigates and records the details of complaints to a good standard. No evidence was provided to show staff have been provided with adult protection training which was verified by staff spoken to. The person in charge did indicate that training in this area was to provided in the near future. Gledhow Lodge J52 S1454 Gledhow Lodge V232371 100605 Stage 4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,22,23,24,26 Overall the home is safe and well maintained but there are areas where the health and safety of service users is compromised. While some rooms are well presented and personalised a number of service users live in rooms that are not. There was an unpleasant smell in some areas creating a disagreeable environment for some service users. EVIDENCE: The location and layout of the home appears suitable for its stated purpose. The large gardens to the rear of the house were found to be well tended and well accessed by the residents and relatives. Precautions to protect service users from the effects of the sun had not been put in place i.e. tables with umbrellas. There was no evidence that service users were offered protection from the sun in the form of hats or sun creams. There were areas within the home that required a risk assessment to ensure resident safety, which included, the steps providing access to the gardens, the Gledhow Lodge J52 S1454 Gledhow Lodge V232371 100605 Stage 4.doc Version 1.30 Page 16 safety gate beside the kitchen and the entrance into the residents lounge. These were highlighted to the person in charge. Many of the rooms were personalised with photographs, mementos and furniture. However, there were a number of residents’ rooms, which had furnishings in need of repair or replacement. Many rooms did not have bedside lights and the facilities for locking away personal belongings could not be accessed due to the fact that they were on top of the wardrobes. No evidence was seen to show the home has a programme for monitoring the quality of furnishings contained within it. There were unpleasant odours in many areas of the home. Although a full time domestic is employed by the home, issues regarding cleanliness and hygiene were identified. Gledhow Lodge J52 S1454 Gledhow Lodge V232371 100605 Stage 4.doc Version 1.30 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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) 27,29 The staff group are receiving a range of training that is aimed at meeting the care needs of the resident group. The recruitment process is not robust enough to ensure the protection of residents. EVIDENCE: The training programme provided to the staff assists them accessing courses that are relevant to the needs of the residents. Staff are now accessing training in the specialist area of dementia and it is recommended that this continue. More evidence is needed to show that the dementia needs of the residents are being provided that is based around current good practice in this field. Training files showed that staff have received training in areas such as emergency aid, infection control, food hygiene and medication administration. Staff were inducted to TOPPS standards and evidence was found to show this was happening. Staff spoken to felt well supported. Relatives of service users spoke very highly of the staff group and felt that they were doing a good job. Resident and relative feedback was positive regarding the ability of staff to provide for care needs. The recruitment procedure being adopted by the home has improved but is still putting residents at risk. Criminal record checks as well as Protection of Vulnerable Adult checks must be carried out on all new employees before work can commence. Gledhow Lodge J52 S1454 Gledhow Lodge V232371 100605 Stage 4.doc Version 1.30 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 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) 31,38. Residents, relatives and staff spoken to were assured that the home was run well. Overall the home is well managed but there are some health and safety practices that compromise the health and well being of the residents and others. EVIDENCE: There were a number of staff identified as working in management roles within the home. A new prospective registered manager has been employed by the home. Staff, residents and relatives were confident in the management approach adopted, and they said that communication was good. The accident books were recording accidents but the follow-up work was insufficient to ensure the health and safety of residents was appropriately met. Residents that had received head injuries had no observations carried out and no referrals made to a GP. Risk assessments of the areas where accidents take place are not made and the existing falls risk assessment for the resident is not reviewed after an accident. This potentially places residents and others at Gledhow Lodge J52 S1454 Gledhow Lodge V232371 100605 Stage 4.doc Version 1.30 Page 19 risk of harm. Alternative space should be found for the storage of the wheelchairs outside of the lounge, as they are also a potential risk to cause injury. Temperatures or the food provided to residents is not recorded at all times with the result being their health and safety is placed at risk. The staff files viewed showed that those staff had received mandatory training in fire safety and manual handling. Gledhow Lodge J52 S1454 Gledhow Lodge V232371 100605 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 2 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION 3 x x 2 3 2 x 1 STAFFING Standard No Score 27 3 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 3 x x x x x x 2 Gledhow Lodge J52 S1454 Gledhow Lodge V232371 100605 Stage 4.doc Version 1.30 Page 21 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 2 Regulation 5 Requirement The registered person must provide residents with a copy of the Terms and Conditions of their stay in the home. The registered person must attempt whenever possible to obtain the involvement of the resident or their representative in developing their care plans. The registered person must ensure that appropriate referals to other health professionals is made when the need is identified. The registered person must make arrangements to ensure the safe storage and administration of medicines in the care home. The registered person must adopt a process that ensures residents receive their own clothes back from the laundry. The registered person must ensure that proper precautions are taken and recorded to prevent harm to the residents when they are sitting in the sun. The registered person must make arrangements , by training staff to help prevent residents J52 S1454 Gledhow Lodge V232371 100605 Stage 4.doc Timescale for action 31st August 2005 31st uly 2005 2. 7 15 3. 8 12 31st July 2005 4. 9 13 31st July 2005 5. 10 12 31st August 2005 31st July 2005 6. 12 13 7. 18 13 31st August 2005 Page 22 Gledhow Lodge Version 1.30 suffering possible abuse. 8. 24 16 The registered person should ensure each resident room contains adequate furnishings that are suitable for their needs. The registered person must keep the home free from offensive odours. The registered person must not employ a person to work at the care home unless all the information highlighted in shedule 2 has been obtained. The registered person must ensure that all parts of the care home that residents have access to are free from hazards to their safety. 31st August 2005 31st August 2005 31st August 2005 9. 10. 26 29 26 19 11. 38 13 31/7/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 19 Good Practice Recommendations A programme of routine maintenance and renewal of the fabric and decoration of the premises should be produced. Gledhow Lodge J52 S1454 Gledhow Lodge V232371 100605 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Aire House Town Street Rodley LS13 1HP 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. 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