Inspection on 04/06/07 for Gledhow Lodge

This inspection was carried out on 4th June 2007.

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

Gledhow Lodge 20/06/06

Gledhow Lodge 21/10/05

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 Hebrew Rawlins Key Unannounced Inspection 4th June 2007 09:00 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 Gledhow Lodge DS0000001454.V331821.R01.S.doc Version 5.2 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.V331821.R01.S.doc Version 5.2 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 Janice Lesley Stevenson Care Home 25 Category(ies) of Dementia - over 65 years of age (25) registration, with number of places Gledhow Lodge DS0000001454.V331821.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th June 2006 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. The home is registered to provide specialised dementia care to older people. Accommodation is provided mainly in single rooms with some double rooms for those who want to share. The home is on two floors and has a passenger lift. There are generous communal areas on the ground floor, offering a choice of lounges and a large dining room. The home has a large, well kept garden where residents can sit out or take a walk. The current scale of charges at the home is £403.00 to 406.89 per week. Additional charges are made for hairdressing, chiropody, cigarettes, newspapers, magazines, alcohol and hosiery. Gledhow Lodge DS0000001454.V331821.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) inspects homes at a frequency determined by how the home has been risk assessed. The inspection process has now become a cycle of activity rather than a series of one-off events. Information is gathered from a variety of sources, one being a site visit. All regulated services will have at least one key inspection between 1st April 2006 and 30th June 2007. This is a major evaluation of the quality of a service and any risk it might present. It focuses on the outcomes for people using it. All of the core National Minimum Standards are assessed and this forms the evidence of the outcomes experienced by people who use the service. More information about the inspection process can be found on our website www.csci.org.uk This visit was unannounced and carried out by one inspector who was at the home on 4th June and gave feedback on 5th June 2007 to the managers. The purpose of the inspection was to make sure the home was operating and being managed for the benefit and well being of the people who use the service and in accordance with requirements. Before the inspection accumulated evidence about the home was reviewed. This included looking at any reported incidents, accidents and complaints. This information was used to plan the inspection visit. During the visit a number of documents were looked at and all areas of the home used by the people living there were visited. A good proportion of time was spent talking with the people who live at the home as well as with the manager and staff. A pre-inspection questionnaire (PIQ) had been completed before the visit to provide additional information about the home. Survey forms were sent out before the visit to the people who use the service, relatives, carers, general practitioners (GPs) and other healthcare professionals. Several were returned and information provided in this way will be reflected in the report. Thanks are extended to everyone who contributed to the inspection and for the hospitality during the visit. Gledhow Lodge DS0000001454.V331821.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The home has maintained a good standard of care to people. All the people living in the home have an up to date contract with the current fee levels detailed. Nutritional assessments of all people who are at risk from weight loss are completed. Accidents reports now show details of when a person living in the home was last seen and there is a section for any follow up or outcome of accidents. The bath with chipped enamel has been replaced. Wheelchairs and zimmer frames are now stored in a safe place to ensure the health and safety of people living in the home. There is now a programme for replacement of furniture and decorating. Gledhow Lodge DS0000001454.V331821.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Gledhow Lodge DS0000001454.V331821.R01.S.doc Version 5.2 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.V331821.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 and 5. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are able to visit the home and have access to written information so that they can make an informed choice about moving in, but they do not always have enough detailed information on how the specialist needs of people with dementia will be met. The home’s pre-admission assessment information does not provide detailed information about the precise needs of people, in all aspects of their care, which means on admission some needs may be overlooked. EVIDENCE: The manager said the home’s Statement of Purpose has been slightly amended since the last inspection. Although the Statement of Purpose outlines what the Gledhow Lodge DS0000001454.V331821.R01.S.doc Version 5.2 Page 10 home can provide and how it intends to achieve that, it does not go into any real detail about the specialist needs of people with dementia. One visitor spoken with who recently had someone admitted to the home said he felt reassured through the whole admission process, particularly as he felt the home had a good reputation locally. He had looked at other homes before visiting Gledhow Lodge, and was given written information about the home and the facilities provided. He felt his relative’s care and support needs were being met very well. All the people living in the home or their representatives have been issued with written contracts. This document states the terms and conditions of occupancy and the weekly charges made by the provider. There were assessment details in the three records sampled, but the home’s pre-admission assessment did not provide sufficient information about the person’s needs and strengths in all aspects of their care, and there was not enough information to form the basis of a care plan. Gledhow Lodge DS0000001454.V331821.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s health care needs are met, and overall medication practices are safe. People’s privacy and dignity is respected. Staff are aware of the specific needs of people in the home but because this is not fully recorded, there is always the possibility that some care may not always be delivered according to that person’s needs and wishes. EVIDENCE: From discussions with staff it was clear that they knew the precise needs of people and provided care based on individual needs and preferences, but this was not always recorded within care plans. The care record format does not lend itself to recording a detailed plan of care, giving clear and precise instructions for staff about how to deliver care according to needs. Gledhow Lodge DS0000001454.V331821.R01.S.doc Version 5.2 Page 12 Throughout the inspection, it could be seen that care and other support given by staff was respectful of privacy, always knocking before entering bedrooms. There was evidence in records that people using the service have access to GPs (General Practitioner), chiropodody, dental and optical services. The survey form returned from GPs stated that the home manages peoples’ health care needs well and always seek to give clients privacy. Medication administration sheets were not always completed for each resident. The records should show when residents refuse their medication and why. If this persists the GP should be informed. There was no photograph of residents on their medication record so as to ensure residents receive the correctly prescribed medication. From discussions with people living in the home it is clear that their dignity and privacy is respected. Gledhow Lodge DS0000001454.V331821.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and15. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who live at the home are able to exercise choice in their daily routines. A good and varied diet is provided for people living in the home. Visitors are made to feel welcome. EVIDENCE: The home provides activities such as quizzes, sing a long, exercise activity, trips to parks and local amenities. Comments from some of the people there indicated that they enjoy the activities. “ I love when the exercise gentleman comes” Gledhow Lodge DS0000001454.V331821.R01.S.doc Version 5.2 Page 14 Staff described the choices available to people and this was confirmed by people living at the home who said that they can go to bed and get up in the morning at a time that suits them. During the inspection people were seen receiving visitors. They said they were comfortable in entering the home and were offered refreshments during their stay. As part of the pre-inspection material requested of the home, a 4-week menu cycle was supplied. This showed there is choice and variety. Mealtime was observed, this was relaxed, people were able to eat in comfortable surroundings and staff were supportive. Comments from all was the food is very good, however they did not know what the meal of the day was until it arrived. Although the daily menu is displayed outside the dining room so that people can see before the actual meal what is being served. Relatives confirmed the standard of meals provided are very good. Staff were knowledgeable about the importance of people retaining as much independence as possible. Throughout the inspection staff were seen to respond to the individual choices of people. Gledhow Lodge DS0000001454.V331821.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There is a robust complaints procedure and people are confident that complaints will be taken seriously. People are protected by a staff team that are aware of what to do if abuse is suspected. EVIDENCE: The complaints procedure is made available to relatives and people who live in the home. It is referred to in the Statement of Purpose. People living in the home and relatives were aware of whom to complaint to if they had concerns. All said they were happy to talk the manager about any concerns. The appropriate policies and procedure were seen to be in place with all the relevant details. Talking to staff on the day it was evident they are all clear on their responsibility about any allegations of abuse and have had training on adult abuse. Gledhow Lodge DS0000001454.V331821.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,23,24,25 and 26. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home offers a safe, well-maintained environment for the service users and they can easily access the garden areas if they so choose. EVIDENCE: Since the last inspection the main bathroom downstairs has had a new suite. A number of bedrooms have been fitted with new carpets. A new gas boiler, new fire alarm system and new emergency light system has been installed. Those bedrooms seen were personalised according to the taste of individual people living at the home. The home now has two domestic staff members which means deep cleaning has taken place and offensive odours are under control. Gledhow Lodge DS0000001454.V331821.R01.S.doc Version 5.2 Page 17 Communal areas and service users’ bedrooms are decorated and furnished to a good standard offering safety and comfort. All returned survey forms completed by people living at the home said that the home is always clean. The manager described the rolling program for redecoration she has contracted out to maintain a good environment for people living at Gledhow Lodge; a start has been made in replacing a number of window frames. Staff described the measures they take to prevent the spread of infection in the home and during the inspection they wore protective clothing when assisting people to the toilet. People living in the home have easy access to the garden, which is well maintained by the home’s contracted gardener. Gledhow Lodge DS0000001454.V331821.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff have the necessary skills to assist and support people living at the home. However there was not enough evidence to show recruitment procedure is robust and staff training was not up-to-date to show that all staff have the relevant training to do their job and protect people. EVIDENCE: During the inspection visit the interaction with staff and the people living in the home was good. Staff were seen to be helpful, sympathetic, caring and had time to chat with people. The Self Assessment returned to the Commission for Social Care Inspection (CSCI) shows that 94 of the staff team have completed a National Vocational Qualification (NVQ) level 2 or above in care. Training in the last twelve months has included health and safety, moving and handling, dementia awareness, fire training, food hygiene and first aid. An annual training plan that identifies when mandatory training updates are due should be developed. Gledhow Lodge DS0000001454.V331821.R01.S.doc Version 5.2 Page 19 The recruitment files of two members of staff, appointed since the last inspection were sampled. It was found that in one case two written references were not obtained. The knock on effects of this could leave people at risk and unprotected. Interview notes/records were not kept, but the necessary checks to make sure that the person was safe and suitable to work with vulnerable people Criminal Record Bureau (CRB) clearance was done. Reflection on staff practice in the home was very positive from people living there and visiting relatives. They complimented the care and kindness in meeting personal needs. Staff spoken to during the inspection displayed a commitment to the service and an understanding of the people in their care. Gledhow Lodge DS0000001454.V331821.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,37, and 38. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home in the main is well managed and the health and safety of people in the home is safeguarded. EVIDENCE: There is a clear commitment by the manager and staff to safeguarding the best interests of people in the home. This is evident from discussions with staff, visiting relatives and people living in the home, and that they hold her in high esteem. Staff described an open and transparent management team who are always willing to help and support. Staff are appropriately supervised. The Gledhow Lodge DS0000001454.V331821.R01.S.doc Version 5.2 Page 21 administration manager had been on sick leave, hence the shortfalls in the record keeping. There are clear records of all peoples’ money and the home has clear policies and procedures about handling people’s monies. The fire alarm system is checked weekly with a different actuation point tested each time. Records are kept of accidents occurring to people in the home, they now show details of when the person was last seen and by whom. There is also a section for any follow up or outcome of the accident. Information supplied with the pre-inspection questionnaire shows that all servicing and maintenance of equipment takes place as necessary. Gledhow Lodge DS0000001454.V331821.R01.S.doc Version 5.2 Page 22 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 2 3 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 X X 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 3 3 Gledhow Lodge DS0000001454.V331821.R01.S.doc Version 5.2 Page 23 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 OP1 Regulation 4 Requirement The statement of purpose must show in detail how the specialist needs of people with dementia will be met. This would give prospective service users more information to make an informed choice about the home. Detailed pre-admission assessments must be carried out to demonstrate how the home can meet assessed need. (not fully completed from 31/08/06) Medication administration sheets must always be completed for each person. The records should show when people refuse their medication and why. Care plans and risk assessments must show in detail the individual and specific care and support needs of people to make sure staff provide person centred care. (not fully completed from31/08/06) Before anyone takes up employment two written references must be obtained and DS0000001454.V331821.R01.S.doc Timescale for action 20/08/07 2. OP3 14 20/08/07 3 OP9 13 20/08/07 4. OP7 15 20/08/07 6 OP29 19 20/08/07 Gledhow Lodge Version 5.2 Page 24 interview notes kept. The knock on effects of this could leave people at risk and unprotected. 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 Refer to Standard OP9 OP30 Good Practice Recommendations There must be photograph of people on their medication record so that they are properly identified and receive the correct medication. An annual training plan that identifies when mandatory training updates are due should be developed. Gledhow Lodge DS0000001454.V331821.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Gledhow Lodge DS0000001454.V331821.R01.S.doc Version 5.2 Page 26 - 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. 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