Inspection on 15/08/05 for Godden Lodge

This inspection was carried out on 15th August 2005.

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 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

Godden Lodge 20/02/08

Godden Lodge 17/10/06

Godden Lodge 02/03/06

Godden Lodge 02/03/06

Godden Lodge 02/03/06

Godden Lodge 15/11/05

Godden Lodge 23/02/05

Godden Lodge 09/08/04

Godden Lodge 22/01/04

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

CARE HOMES FOR OLDER PEOPLE Godden Lodge - Cephas House 57 Hart Road Thundersley Benfleet Essex SS7 3GL Lead Inspector Carolyn Delaney Un-announced 15th August 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. Godden Lodge - Cephas House I56-I06 S15536 Godden Lodge - Cephas V244554 150805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Godden Lodge - Cephas House Address 57 Hart Road, Thundersley Benfleet Essex SS7 3GL 01268 792227 01268 565474 warnersu@bupa.com BUPA Care Homes Limited 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) Mrs Sunita Warner CRH 120 Category(ies) of DE (E) Dementia - over 65 60, OP Old Age 55, registration, with number PD Physical Disability 7, TI Terminally Ill 5. of places Godden Lodge - Cephas House I56-I06 S15536 Godden Lodge - Cephas V244554 150805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. People who have a diagnosed physical disability to be nursed on Cedars House Only. 2. People who have a diagnosed Terminall illness to be nursed on Cephas House only and be aged over 40 years. 3. People who have a diagnosis of Dementia to be nursed on Boyce and Murelle House only. Date of last inspection 23rd February 2005 Brief Description of the Service: Cephas House is one of four houses which make up Godden Lodge. Cephas House provides nursing care for up to a maximum of thirty older people, including up to a maximum of five people who have a diagnosed Terminal Illness.The house provides each resident with their own bedroom and access to clean, comfortable and well maintained communal areas including a combined lounge and dining area and garden space.Godden Lodge is situated close to bus routes to Southend and Rayleigh and local shops and amenities. Godden Lodge - Cephas House I56-I06 S15536 Godden Lodge - Cephas V244554 150805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced inspection carried out on 15th August 2005 between the hours of 14.50 18.30. Michelle Love, inspector and Carolyn Delaney, Lead Inspector for the home, carried out the inspection. Records including care plans and assessments in respect of residents’ needs and risks to health, safety and welfare were examined. Three residents and four visitors to the home were spoken with and their views about the home, how it is managed and the care provided were obtained. Records in respect of staff recruitment, induction and training were assessed and two members of staff were spoken with during the inspection. Records in respect of the maintenance and safety checks for the home were assessed. As this is the first time that Cephas House has had a separate inspection there are no regulatory requirements or National Minimum Standard recommendations carried forward from the previous inspection. Information in respect of standards twenty-nine, thirty and thirty-one to thirty-eight, staff recruitment, training and the management of the home were assessed with the homes Registered Manager. Any regulatory requirements identified in the report in respect of these standards are not a reflection of what was observed on Cephas House but in general in the home as a whole. What the service does well: Cephas House provides a safe and comfortable place for people who require nursing care. Staff are well supported and receive training so as to understand and meet the needs of the people who live at the home. Staff work well as a team and spend time interacting with residents. Godden Lodge - Cephas House I56-I06 S15536 Godden Lodge - Cephas V244554 150805 Stage 4.doc Version 1.40 Page 6 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. Godden Lodge - Cephas House I56-I06 S15536 Godden Lodge - Cephas V244554 150805 Stage 4.doc Version 1.40 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 Godden Lodge - Cephas House I56-I06 S15536 Godden Lodge - Cephas V244554 150805 Stage 4.doc Version 1.40 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) 3 & 4 Qualified nursing staff carry out detailed assessments of nursing and general care needs prior to offering a place at the home and prospective residents and / or their families are encouraged to visit the home so as to assess its suitability. Staff working on Cephas house receive training specific to the needs of the people who live there. EVIDENCE: Assessments carried out in respect of the needs of people prior to them being offered a place at the home were noted to be detailed. Information in respect of people admitted to the home was noted to be reviewed on a regular basis so as to ensure that staff working at the home were aware of their needs and any changes to treatment etc. There was evidence that staff working on Cephas House were well supported by senior nursing staff and that they received training and information so as to ensure that residents nursing, care and welfare needs were met. Godden Lodge - Cephas House I56-I06 S15536 Godden Lodge - Cephas V244554 150805 Stage 4.doc Version 1.40 Page 9 Godden Lodge - Cephas House I56-I06 S15536 Godden Lodge - Cephas V244554 150805 Stage 4.doc Version 1.40 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 Staff working on Cephas House act in a manner so as ensure that resident’s nursing and care needs are met and that risks to their safety, health and welfare are assessed and managed. EVIDENCE: Care plans in respect of the needs of the people living on Cephas house were detailed and kept up to date and accurate. Residents wishes, preferences and capabilities in respect of daily activities of living were clearly recorded where the resident was capable of providing this information. There were detailed care plans in place for each resident detailing the care required and where risks to residents health and safety, such as risks of developing pressure sores or injuries through falls had been identified there were clear plans in place so as to minimise these risks. Medication is administered by qualified nursing staff and where residents choose to retain and administer their medication this is facilitated following an assessment of any risks to the individual. Godden Lodge - Cephas House I56-I06 S15536 Godden Lodge - Cephas V244554 150805 Stage 4.doc Version 1.40 Page 11 On the day of the inspection it was noted that the lunchtime medications were given late as a member of staff had left the unit to escort a resident to hospital and had taken the keys to the medicine cupboard. The senior member of staff was not aware that a spare set of keys was available in the manager’s office. This was discussed with the homes manager. Godden Lodge - Cephas House I56-I06 S15536 Godden Lodge - Cephas V244554 150805 Stage 4.doc Version 1.40 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 & 15 The provision of meaningful social and occupational activities does not meet the needs of all residents living on Cephas House. Residents of Cephas House are facilitated so far as it is possible to maintain social contacts with family and friends. Staff working on Cephas House ensure that residents receive a balanced and nutritious diet, which meets the individuals dietary needs and preferences. EVIDENCE: Some residents who were spoken with during this inspection said that they felt that there was little provided in the way of activities which they enjoyed. One resident said that they would like to be supported by staff to go out to local shops but that staff were generally too busy. Both residents and their relatives who were spoken with during the course of this inspection said that they were happy with the care provided by the home. Relatives said that they were always made to feel welcomed and were kept informed of any changes to residents health and general condition. All residents who were spoken with confirmed that they were happy with the food provided by the home. One resident said that he preferred to have a Godden Lodge - Cephas House I56-I06 S15536 Godden Lodge - Cephas V244554 150805 Stage 4.doc Version 1.40 Page 13 bacon sandwich most evenings at suppertime and that staff were happy to provide this. Staff were observed to assist residents at their evening meal. It was positive to note that staff attended residents in an unhurried manner at this time. There were detailed records maintained in respect of each residents nutritional needs and that these records were updated on a regular basis and according to any changes in residents needs. Godden Lodge - Cephas House I56-I06 S15536 Godden Lodge - Cephas V244554 150805 Stage 4.doc Version 1.40 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 People living on Cephas House and their relatives feel confident that any complaints they have will be dealt with satisfactorily. Staff working at the home are aware of adult protection issues and what actions they should take if they witness or suspect abuse of any people living there. EVIDENCE: There have been no complaints made to the Commission for Social Care Inspection in respect of Cephas House since the last inspection. Nine complaints had been received and investigated by the home since the previous inspection. These complaints were in respect of missing laundry items and the quality of food. There was evidence that all complaints were investigated and complainants responded to appropriately. Residents and relatives said that if they had issues that they felt they would be resolved satisfactorily. All staff receive information and training in respect of the protection of vulnerable people, as part of their induction. Boyce House has a copy of the local Social Services Protection of Vulnerable Adults policy and procedures. Staff could demonstrate that they were aware of the appropriate action to take if they witnessed or suspected abuse of any people living at the home. Godden Lodge - Cephas House I56-I06 S15536 Godden Lodge - Cephas V244554 150805 Stage 4.doc Version 1.40 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, 20 & 26 People living at the home are provided with a safe, comfortable and wellmaintained place to live. EVIDENCE: Each resident living in Cephas House has their own bedroom, which may be personalised with decorations and furnishings according to the individual’s choice. Residents have access to a large open plan lounge / dining room and secure well maintained garden area. Cephas House has dedicated domestic staff. On the day of the inspection some isolated odours were detected in the lounge areas and some of the corridors. The manager said that the regular domestic was not on duty and that a temporary member of domestic staff was working on Cephas. Godden Lodge - Cephas House I56-I06 S15536 Godden Lodge - Cephas V244554 150805 Stage 4.doc Version 1.40 Page 16 Records evidenced that appropriate checks in respect of safety and maintenance of the home and any necessary repairs were carried out regularly. Godden Lodge - Cephas House I56-I06 S15536 Godden Lodge - Cephas V244554 150805 Stage 4.doc Version 1.40 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 & 30 Staff are employed in suitable numbers and with an appropriate skill mix so as to meet the needs of the people who live at the home. Staff recruitment is generally robust in respect of protecting residents at the home. EVIDENCE: Duty rotas indicated that staff were employed in sufficient numbers so as to meet the needs of the people who live there. Staff have appropriate off duty days and do not work excessive hours without a break. Staff working on Cephas House on the day of the inspection were noted to interact in a positive manner, spending time chatting and providing stimulation with residents. Records in respect of the recruitment of staff were kept centrally in the Registered Managers office. A selection of these were sampled. There was evidence that appropriate checks including references from previous employers and PoVA First checks / Criminal Records Bureau (CRB) checks were obtained, and interviews were carried out prior to individuals being offered employment at the home. Some issues in respect of the standard and proficiency of English for some overseas staff was highlighted during the overall inspection (but not specifically noted on Cephas House on the day of this inspection) There was evidence that staff working at Godden Lodge receive mandatory training with regular updates and a detailed induction. Records in respect of Godden Lodge - Cephas House I56-I06 S15536 Godden Lodge - Cephas V244554 150805 Stage 4.doc Version 1.40 Page 18 staff training to meet the needs of people living at the home such as care planning, risk management wound care etc, were not consistently maintained but the manager had developed a system for recording training for all staff working at the home. Godden Lodge - Cephas House I56-I06 S15536 Godden Lodge - Cephas V244554 150805 Stage 4.doc Version 1.40 Page 19 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 Cephas House is managed so as to best meet the needs, health, safety and welfare of the people who live there. EVIDENCE: A senior nurse, head of home who reports to the Registered Manager, carries out the day-to-day management of Cephas House. Residents and visitors to Boyce House said that the home was well managed. It was positive to note that at the time of this inspection while the head of home had been absent for a period of time (offering support to another local BUPA home), Senior nursing staff had effected and maintained improvements in the standards of care practices in this house. Regular fire safety checks and checks in respect of electrical and mechanical equipment are carried out on a regular basis so as to safeguard the people who live in, work at and visit the home. Godden Lodge - Cephas House I56-I06 S15536 Godden Lodge - Cephas V244554 150805 Stage 4.doc Version 1.40 Page 20 Godden Lodge - Cephas House I56-I06 S15536 Godden Lodge - Cephas V244554 150805 Stage 4.doc Version 1.40 Page 21 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 x x 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 x x x x x 2 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x x x x x x 3 Godden Lodge - Cephas House I56-I06 S15536 Godden Lodge - Cephas V244554 150805 Stage 4.doc Version 1.40 Page 22 NA 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 OP9 Regulation 13(2) Requirement Timescale for action Immediate & ongoing 2. OP12 16(2) 3. OP26 23(2)(d) The registered persons must ensure that all staff working at the home are aware of all information in respect of the administration of medicines so as to ensure that residnets at the home receive medication at the times for which it is prescribed. The registered persons must 30/12/05 ensure that so far as it is practicable that the home provides a programme of activities which meets the needs and wishes of people living at the home. The registered persons must Immediate ensure that so far as it is & ongoing practicable that the home is maintained free from offensive odours. 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. Godden Lodge - Cephas House I56-I06 S15536 Godden Lodge - Cephas V244554 150805 Stage 4.doc Version 1.40 Page 23 Refer to Standard Good Practice Recommendations Godden Lodge - Cephas House I56-I06 S15536 Godden Lodge - Cephas V244554 150805 Stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection Kingswood House Baxter Avenue Southend on sea Essex SS2 6BG 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 Godden Lodge - Cephas House I56-I06 S15536 Godden Lodge - Cephas V244554 150805 Stage 4.doc Version 1.40 Page 25 - 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!