Inspection on 15/11/05 for Godden Lodge

This inspection was carried out on 15th November 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 15/08/05

Godden Lodge 15/08/05

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 - Murrells 57 Hart Road Thundersley Benfleet Essex SS7 3GL Lead Inspector Carolyn Delaney Un-announced 15 November 2005 th 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 - Murrells I56-I06 S15536 Godden Lodge - Murrells V244473 151105 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Godden Lodge - Murrells Address 57 Hart Road Thundersley Essex SS7 3GL 01268 792227 01268 565474 warnersu@bupa.com BUPA Care Home 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 PD registration, with number Physical Disability 7, TI Terminally Ill 5 of places Godden Lodge - Murrells I56-I06 S15536 Godden Lodge - Murrells V244473 151105 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd February 2005. Brief Description of the Service: Murrelle House is one of the four houses which make up Godden Lodge. Murrelle House provides nursing care and accommodation for up to thirty people who have a diagnosis of Dementia. The house provides each resident with their own bedroom and access to clean 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 - Murrells I56-I06 S15536 Godden Lodge - Murrells V244473 151105 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 November 2005 between the hours of 13.00 and 17.30. 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 two visitors to the home were spoken with and their views about the home, how it is managed and the care provided were obtained. Three members of staff were spoken with during the inspection. As this is the first time that Murrelle House has had a separate inspection there are no regulatory requirements or National Minimum Standard recommendations carried forward from the previous inspection. What the service does well: What has improved since the last inspection? The recording of information about residents including care plans and records in respect of assessing and managing risks to health and safety have continued to improve over the previous eighteen months. Godden Lodge - Murrells I56-I06 S15536 Godden Lodge - Murrells V244473 151105 Stage 4.doc Version 1.40 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. Godden Lodge - Murrells I56-I06 S15536 Godden Lodge - Murrells V244473 151105 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 - Murrells I56-I06 S15536 Godden Lodge - Murrells V244473 151105 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 Staff working on Murrelle House ensure that people are only admitted to the home following an assessment process to determine that their nursing and care needs can be met. EVIDENCE: Detailed assessments are carried out to determine prospective residents nursing and care needs before they are offered a place at the home. Relatives of residents, who were spoken with during this inspection confirmed that they had the opportunity to visit the home prior making any decision about whether to make a placement. They had also been provided with a copy of the homes most recent inspection report. It was positive to note that the Behavioural Assessment of Later Life (BASOLL) assessment was completed correctly and clearly identified the key needs for each individual living at the home Staff working on Murrelle house receive training in respect of the needs of the people for whom they provide care. Murrelle House does not provide rehabilitative or intermediate care. Godden Lodge - Murrells I56-I06 S15536 Godden Lodge - Murrells V244473 151105 Stage 4.doc Version 1.40 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8, & 9 Staff working on Murrelle House document each residents needs in a plan of care, which is kept up to date, so as to ensure that all staff are aware of each individuals needs and how these needs are to be met. Staff assess and manage risks to resident’s health and wellbeing. Staff do not consistently record information in respect of the administration and disposal of medicines or store medicines appropriately. EVIDENCE: There were detailed care plans in respect of each persons nursing, healthcare and general needs and these plans were kept up to date in respect of any changes to residents needs. Where residents expressed preferences in respect of daily activities of living these were documented within the care plans. There were detailed assessments recorded in respect of risks to residents of sustaining injury, such as risks associated with the use of bedrails and risks of injuries from falls etc. These documents were reviewed on a regular basis and Godden Lodge - Murrells I56-I06 S15536 Godden Lodge - Murrells V244473 151105 Stage 4.doc Version 1.40 Page 10 where risks were identified there were plans in place to manage these risks and so minimise the impact on residents living at the home. Staff raised some issues in respect of the disposal of medicines. The system for the disposal of medicines had been changed since the previous inspection and staff were required to store medicines to be disposed of in a container, which would be collected periodically. Staff were concerned that these medicines could be accessed from the container prior to this being collected. These issues were discussed with the homes manager who said that there had been some problems with the company contracted to collect unused medicines but that this was being addressed and a more suitable container would be provided. It was noted with concern that medicines, which had been refused by residents on Murrelle House, were not stored safely and records in respect of these medicines were not consistently maintained. Godden Lodge - Murrells I56-I06 S15536 Godden Lodge - Murrells V244473 151105 Stage 4.doc Version 1.40 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 & 13 The provision of meaningful social and occupational activities on Murrelle House is not consistently maintained. Residents are encouraged and supported in maintaining relationships with family and friends. EVIDENCE: Godden Lodge employs an activities coordinator to provide a range of activities for the people living on Murrelle House. The activities coordinator was not on duty on the day of the inspection. Staff said that one to one and group activities were provided and that where residents were capable and wished to they were supported to go out to local shops etc. It was noted that there was very little in the way of stimulation or activities provided for residents on the day of the inspection. This was discussed with the homes manager. Visitors and relatives who were spoken with on the day of the inspection said that they were always made to feel welcome when they visited. Godden Lodge - Murrells I56-I06 S15536 Godden Lodge - Murrells V244473 151105 Stage 4.doc Version 1.40 Page 12 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 Murrelle 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 Murelle House since the last inspection. All complaints received by the home had been investigated and responded to appropriately. Relatives who were spoken with 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 - Murrells I56-I06 S15536 Godden Lodge - Murrells V244473 151105 Stage 4.doc Version 1.40 Page 13 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 and well-maintained place to live. The communal dining / lounge area are not as comfortable or homely as those in other houses on site. Murrelle House was maintained clean and free from unpleasant odours. EVIDENCE: Each resident living in Murrelle 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. The main communal area was noted to be sparsely decorated and did not feel homely. It was reported that new chairs and furniture had been ordered and that there were plans to redecorate the communal areas. Godden Lodge - Murrells I56-I06 S15536 Godden Lodge - Murrells V244473 151105 Stage 4.doc Version 1.40 Page 14 Murrelle House has dedicated domestic staff. On the day of the inspection the house was noted to be clean and free from unpleasant odours throughout. Records evidenced that appropriate checks in respect of safety and maintenance of the home and any necessary repairs were carried out regularly. Godden Lodge - Murrells I56-I06 S15536 Godden Lodge - Murrells V244473 151105 Stage 4.doc Version 1.40 Page 15 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 working on Murrelle House do not act consistently in a manner, which best meets, the needs of the people who live there. Staff recruitment is generally robust in respect of protecting residents at the home. Staff working at the home receive appropriate training and support in respect of the roles they are to perform and the needs of the people who live at the home. EVIDENCE: Some staff working on Murrelle House said that the number of staff had been reduced and that this had an impact on the care provided to residents living at the home. On the day of the inspection there were two qualified nurses and three care assistants on duty. It was noted that while care assistants were busy providing personal care that on occasions the qualified staff did not appear to be busy or to interact with residents. The issues raised by staff on Murrelle House were discussed with the homes manager who said that the staffing levels had been reviewed and that while the numbers of staff currently employed on Murrelle House were in accordance with those previously agreed that the numbers were to be increased by one from January 2006, however as the house had a number of vacant beds the current staffing levels were sufficient. The issues in respect of the deployment Godden Lodge - Murrells I56-I06 S15536 Godden Lodge - Murrells V244473 151105 Stage 4.doc Version 1.40 Page 16 of staff and working practices on the House were discussed with the homes manager. Records in respect of the recruitment of staff were kept centrally in the Registered Managers office. A selection of these was sampled during the inspection of the other three houses on 15th August 2005. 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. There was evidence that staff working at Godden Lodge receive mandatory and relevant specialist training with regular updates. Godden Lodge - Murrells I56-I06 S15536 Godden Lodge - Murrells V244473 151105 Stage 4.doc Version 1.40 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 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) 38 Murrelle House is maintained so as to promote the safety and welfare of residents, staff and visitors to the home. EVIDENCE: 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 - Murrells I56-I06 S15536 Godden Lodge - Murrells V244473 151105 Stage 4.doc Version 1.40 Page 18 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 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 x COMPLAINTS AND PROTECTION 3 2 x x x x x 3 STAFFING Standard No Score 27 2 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 x x x x x x x 3 Godden Lodge - Murrells I56-I06 S15536 Godden Lodge - Murrells V244473 151105 Stage 4.doc Version 1.40 Page 19 N/A 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 The registered persons must ensure that staff practices in respect of the safe storage and recording in respect of medicines receiveed into the home are appropriate and in accordance with current legislation and good practice guidelines. The registered persons must 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 ensure that the deployment of staff on Murrelle House is suited to the needs of the people who live there and that staff act in accordance with the homes policies, procedures and expectations. Timescale for action Immediate & ongoing 2. OP12 16(2) 30/01/06 3. OP27 30/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Godden Lodge - Murrells I56-I06 S15536 Godden Lodge - Murrells V244473 151105 Stage 4.doc Version 1.40 Page 20 No. 1. Refer to Standard OP20 Good Practice Recommendations It is recommended that the layout and decoration of the communal area be reviewed so as to provide a more homely and comfortable environment for residents. Godden Lodge - Murrells I56-I06 S15536 Godden Lodge - Murrells V244473 151105 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection Kingswood House Baxter Avenue Southend on sea SS6 2BG 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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