Inspection on 21/10/05 for Gledhow Lodge

This inspection was carried out on 21st October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Gledhow Lodge 04/06/07

Gledhow Lodge 20/06/06

Gledhow Lodge 10/06/05

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 Inspection 21st October 2005 09:30 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 Gledhow Lodge DS0000001454.V260331.R01.S.doc Version 5.0 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. Gledhow Lodge DS0000001454.V260331.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Gledhow Lodge Address 51/53 Gledhow Wood Road Leeds West Yorkshire LS8 4DG 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) 0113 266 7806 Yorkshire Residential Care Limited Mrs Andrea Atkinson Care Home 25 Category(ies) of Dementia - over 65 years of age (25) registration, with number of places Gledhow Lodge DS0000001454.V260331.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th June 2005 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. 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 DS0000001454.V260331.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out by one inspector 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. A number of documents were examined which included care plans, staff files and policies and procedures. What the service does well: What has improved since the last inspection? What they could do better: Gledhow Lodge DS0000001454.V260331.R01.S.doc Version 5.0 Page 6 The following are areas that the home must improve: • • Evidence must be provided by the home to show how the Specialist Dementia needs of the residents are provided for. Where a resident care need is identified it must be highlighted within the care plan. Residents/relatives or advocates must be involved with the assessment and care planning process. Where risks to the service users health have been identified these must be thoroughly assessed and a plan of care developed to help minimise this risk. This refers to areas such as pressure sore development, falls, nutrition. When a resident requires referral to another health professional this must be done. Improvements must be made with the administration and storage of medication in the care home. Relevant training must be provided to all care staff involved with this process. Improvements must be made to ensure the privacy and dignity of the residents is respected. A more structured provision of activities must be provided to ensure residents’ wishes are taken into account. Improvements must be made with Adult Protection systems used by the home. Adult protection training must be provided to all care staff. More work must be carried out to ensure odours are eradicated from the home. All the necessary information must be obtained before an employee takes up their position in the home. The management systems adopted by the home must be reviewed to ensure there are clear lines of accountability. The Registered person must ensure that the Health and safety of residents and the staff are protected at all times. • • • • • • • • • • Gledhow Lodge DS0000001454.V260331.R01.S.doc Version 5.0 Page 7 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 DS0000001454.V260331.R01.S.doc Version 5.0 Page 8 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 Gledhow Lodge DS0000001454.V260331.R01.S.doc Version 5.0 Page 9 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): 3,4. Residents are assessed prior to moving into the home. The home does not ensure the residents Specialist Dementia needs will be met. EVIDENCE: The care files of three residents showed that the home does obtain an assessment prior to admission. Two relatives spoken to stated that they did have the opportunity come and visit for an afternoon, which they accepted. The care home offers specialist care for people with the specialist need of Dementia. The care files examined showed no evidence to suggest that the specialist dementia care needs were being met. The care files showed very little reference to dementia and there was no evidence to see the care provided was based on current good practice. The carers that were spoken were unable to identify how the specialist needs are met. The home does not adopt a person centred care approach but focuses mostly on trying to meet the personal care needs of residents. Gledhow Lodge DS0000001454.V260331.R01.S.doc Version 5.0 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 the following standard(s): 7,8,9,10. The residents’ plans seen during the inspection showed not all residents health, personal and social care needs are set out in a plan of care. It was clear from the documentation seen that the health care needs of all the residents are not being fully met. The policies and procedures adopted by the home to deal with the administration and storage of medication do not ensure the residents are properly protected. Although the care team appear friendly and kind evidence was found to show that the home does not ensure the privacy and dignity of all the residents is respected whenever possible. EVIDENCE: Three care plans were inspected. From these it was identified that the home has made improvements with the care plans with regards to the involvement Gledhow Lodge DS0000001454.V260331.R01.S.doc Version 5.0 Page 11 of the residents and their representatives. Two relatives spoken to confirmed that they were asked to be involved with the process and did sign a document to agree this. One resident was identified as needing nursing care after being assessed by district nurses. The home had not carried out a new assessment. Care needs identified that needed care plans such as nutrition and pressure area care had not been implemented and this left the resident at risk. The assessments for the residents had gaps where they had not been completed. Where risks such as aggressive behaviour, falls and pressure sores were identified risk assessments and care plans were not written to assist staff with ensuring these care needs could be met. One resident was identified as having recently lost a lot of weight but the home had not referred this person to an appropriate health professional. Falls risk assessments were not reviewed after residents had fallen which meant that possible new risks were not being identified and eliminated. The medicine records of three residents were reviewed and were appropriately filled in. The local pharmacist is now involved with the dispensing of medication in the home. The Commission is investigating this system of dispensing medication further, as it may not meet the Royal Pharmaceutical Guidelines for the Administration of Medication. Medications were found stored in the kitchen beside the serving hatches. Staff spoken to said that this was normal practice. This is a serious lapse in the home’s system for storing medication and the person in charge was informed that this practice should cease immediately as it placed residents and others at risk of harm. Residents were seen to be treated and spoken to with kindness and regard by the staff on duty. Relatives spoken to praised the staff and said they felt that they did their best to ensure privacy and dignity was maintained. During the inspection it was identified that the manager had moved one resident into another resident’s room so that maintenance work could be carried out. The manager stated that it was ok to do this, as the resident didn’t sleep in their room but slept in the lounge. No written evidence was found to show there was any consultation for this move. The doors to residents’ private rooms have recently been locked when they get up in the morning. The registered manager took this decision due to the fact that some residents have been wandering into rooms. This is not good practice and is restricting the residents’ privacy and dignity. This was discussed with the registered manager and it was recommended that another way of dealing with this issue be found. Residents’ privacy and dignity was further compromised by the storing of one residents clothes and furnishings in the private room of another resident. Relatives of one resident were seen to enter another resident’s room in order to retrieve some clothing. This is not acceptable. Gledhow Lodge DS0000001454.V260331.R01.S.doc Version 5.0 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 the following standard(s): 12,13,15 The activities provided to service users in the home do not take into consideration the preferences and interests of the residents living there. The visiting times are flexible and the home encourages relatives to visit whenever possible. Service users receive regular meals in suitable settings. More work is needed to ensure the menus are devised alongside the likes and dislikes of the residents living at the home. EVIDENCE: The home has begun to improve the provision of activities to residents. Two relatives spoken to stated that there have been a number of activities on offer including a daytrip to Roundhay Lake, Firework Display and Autumn Fair. A gentleman comes in on a weekly basis to provide light entertainment to residents. One carer has attended an Activities and Therapeutic course and is looking to develop the provision of activities further. It is hoped that these will be more individualised and meet the needs of the individual resident. Relatives are able to visit at any time and they said that they are made feel welcome by all the staff they come into contact with. Gledhow Lodge DS0000001454.V260331.R01.S.doc Version 5.0 Page 13 It was difficult to ascertain the residents’ view of the food offered by the home, but they appeared to enjoy the food that was presented to them. One resident stated “ The foods alright. Its not what I would want but I do eat it.”Residents were offered hot and cold drinks at regular intervals. It was confirmed that they receive three meals per day at regular intervals. Staff were seen to be helpful in assisting those residents that had difficulty eating their meals. A member of staff involved with the food provision felt that there were areas that could be improved upon with regards to quality of the food brought into the home. This was highlighted with the registered manager and it was recommended that the cook be more involved with the purchase of foods brought into the home. No evidence was seen to show that the foods provided to residents were based around their own personal preferences and likes. There were a number of environmental health issues identified with the recording systems adopted by staff in the kitchen, mainly relating to cleaning and temperature checks of cooked foods, freezers and fridges. Gledhow Lodge DS0000001454.V260331.R01.S.doc Version 5.0 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 the following standard(s): 18 Residents are not suitably protected by the policies and procedures adopted by the home with regards to Adult Protection. EVIDENCE: Staffs, including the Registered Manager, are unfamiliar with the correct Adult Protection procedures to follow if the need arises. This was evidenced on the day of the inspection when a very serious incident occurred during the night shift. The inspector had to inform the person in charge and the registered manager as to who they should inform regarding this matter. Staff are not suitably trained in this area. The procedure for referral of adult protection issues is not easily accessible and needs to be reviewed so that the process for referral to other agencies is much clearer. Gledhow Lodge DS0000001454.V260331.R01.S.doc Version 5.0 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 the following standard(s): 26 The home appears clean and tidy. Offensive odours continue to be a problem for the home to erradicate. EVIDENCE: Two relatives spoken to stated that they felt the home always appeared tidy and clean when they entered. The manager stated that they are trying hard to eradicate unpleasant odours from the home. However, there were a number of areas identified during the inspection where these were identified. This is a reoccurring issue within the home and has been identified on a number of inspections. Gledhow Lodge DS0000001454.V260331.R01.S.doc Version 5.0 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. Insufficient levels of domestic staff are employed by the care home, as Care Staff are still involved with the domestic duties of the home. Increased levels of staff trained to NVQ level 2 are needed. The recruitment procedure implemented by the home does not thoroughly ensure residents are being properly protected. EVIDENCE: The home has recently employed a part time cleaner the care staff are still involved with the domestic duties as part of their role. This involves cleaning and laundry tasks. This role takes them away from their care role. The registered person is still working towards ensuring that 50 of staff are trained to NVQ level 2 standard or above. Staff spoken to were keen to attain this training as they realised it would help improve the standard of care provision. The staff file of the most recent employee was inspected and it was identified that the necessary checks were not obtained prior to starting employment. A POVA check had not been carried out prior to employment commencing and therefore placed residents at possible risk. Staff spoken to stated that they did have an induction but this only involved being shown around the home and didn’t include a formal process designed to the Skills for Care specification. Gledhow Lodge DS0000001454.V260331.R01.S.doc Version 5.0 Page 17 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): 31,38. The management structure should be reviewed as residents and staff are not presently benefiting from the management processes adopted by the home. The Health and Safety of residents and staff is being put at risk by the poor systems used for monitoring these issues. EVIDENCE: The home has employed a new manager and an application for registration is currently being processed for that individual. Conversations with a significant proportion of staff and residents highlighted that they are not very sure as to who has full responsibility for the management of the home. They said that as far as they were aware there are at least four people involved with the management role in the home. This has had a contributing factor to the staff group experiencing a low morale at present. They feel that there is a lack of leadership within the home. Three members of staff spoken to felt unable to approach the management, as they do not think they would be supported appropriately. No evidence was provided to show regular resident/relative Gledhow Lodge DS0000001454.V260331.R01.S.doc Version 5.0 Page 18 meetings or staff meetings are held regularly. A number of serious incidents have occurred in the home and the registered manager has failed to notify the Commission. There were a number of Health and safety issues identified that placed the residents and staff at risk: • The Passenger Lift did not have an up to date certificate • The 5-year Electrical Wiring Certificate was out of date. • The Gas Appliances had not been appropriately checked. • Bed rails were not checked. • Hot water outlets had not been checked. • A fire door that was held open and fully restricted from closing by the use of string being tied to a chair. • Environmental risk assessments not reviewed at a regular interval. These are examples of the health and safety issues highlighted during the inspection. Gledhow Lodge DS0000001454.V260331.R01.S.doc Version 5.0 Page 19 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 x x 3 2 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 1 x x x x x x x 2 STAFFING Standard No Score 27 2 28 2 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x x x x x x 1 Gledhow Lodge DS0000001454.V260331.R01.S.doc Version 5.0 Page 20 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 OP4 Regulation 12 Requirement The registered person must demonstrate the homes capacity to meet the assesessed specialist Dementia needs of the residents. Residents’ health, personal and social care needs must be set out in individual plans. All assessments and care plans must show that the resident or their representative have been involved with the process. The previous timescale of 31/7/05 was not met. When a resident has been assessed as being at risk of developing pressure sores the appropriate intervention must be taken and recorded in the care plan. The registered person must ensure that appropriate referrals to other health professionals are made when the need is identified. (The previous timescale of 31/7/05 was not met) The registered person must make arrangements to ensure the safe storage and DS0000001454.V260331.R01.S.doc Timescale for action 31/01/06 2 OP7 15 31/01/06 3 OP8 12,13 31/01/06 4 OP8 12,13 31/01/06 5 OP9 13 31/01/06 Gledhow Lodge Version 5.0 Page 21 6 OP9 13 7 OP10 12 8 OP12 16 9 OP18 13 10 OP26 26 11 OP29 19 12 OP38 13 13 OP31 12 14 OP38 37 administration of medicines in the care home. (The previous timescale of 31/7/05 was not met) The registered person must ensure that all carers dealing with the administration of medications are suitably trained. The registered person must ensure residents privacy and dignity are respected at all times. The registered person must consult residents or their representatives regarding the programme of activities arranged by or on behalf of the care home. The registered person must make arrangements, by training staff, to help prevent residents suffering possible abuse.(The previous timescale of 31/08/05 was not met) The registered person must keep the home free from offensive odours. (The previous timescale of 31/08/05 was not met.) The registered person must not employ a person to work at the care home unless all the information highlighted in Schedule 2 has been obtained. (The previous timescale of 31/08/05 was not met) The registered person must ensure that all parts of the care home that residents have access to are free from hazards to their safety. (The previous timescale of 31/7/05 was not met) The registered manager must have clear lines of accountability and meet all standards that apply. The registered person must DS0000001454.V260331.R01.S.doc 31/03/06 31/01/06 28/02/06 28/02/06 28/02/06 31/12/05 31/12/05 31/01/06 30/11/05 Page 22 Gledhow Lodge Version 5.0 inform the Commission of any notifiable incident. 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. 2 3 Refer to Standard OP19 OP15 OP27 Good Practice Recommendations A programme of routine maintenance and renewal of the fabric and decoration of the premises should be produced. The registered person should ensure residents receive a menu that is suited to individual assessed and recorded needs. Domestic staff should be employed in sufficient numbers to ensure to ensure the home is in a clean and hygienic state. Gledhow Lodge DS0000001454.V260331.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Aire House Town Street Rodley Leeds 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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