Inspection on 02/03/06 for Godden Lodge

This inspection was carried out on 2nd March 2006.

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

Godden Lodge 20/02/08

Godden Lodge 17/10/06

Godden Lodge 15/11/05

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 57 Hart Road Thundersley Benfleet Essex SS7 3GL Lead Inspector Carolyn Delaney Unannounced Inspection 07:00 2 & 3 March 2006 nd rd 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 Godden Lodge DS0000015536.V261234.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. Godden Lodge DS0000015536.V261234.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Godden Lodge Address 57 Hart Road Thundersley Benfleet Essex SS7 3GL 01268 792227 01268 565474 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) BUPA Care Homes Limited Mrs Sunita Warner Care Home 120 Category(ies) of Dementia (60), Dementia - over 65 years of age registration, with number (60), Old age, not falling within any other of places category (55), Physical disability (7), Terminally ill (10) Godden Lodge DS0000015536.V261234.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. People who have a diagnosed physical disability to be nursed on Cedars House only. People who have a diagnosed Terminal Illness to be nursed on Cephas House only and be aged over 40 years. People who have a diagnosis of Dementia to be nursed on Boyce and Murelle House only. 15th November 2005 Date of last inspection 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 DS0000015536.V261234.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced inspection carried out on 2nd & 3rd March 2006 between the hours of 07.00 and 16.00. 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. Two residents were spoken with however due to the level of cognitive impairment it was not possible to fully obtain their views as to how the home is managed and the care provided. The relatives of ten residents at the home, the Lead Reviewing Nurses for Castle Point & Rochford Primary Care Trust and the local Tissue Viability Nurses Specialist were contacted by post so as to offer them the opportunity to make comments about the services provided by the home. A summary of the comments made will be included in the final version of the report. Five members of staff were spoken with during the course of this inspection so as to determine their awareness of the needs and wishes of the people living at the home and the homes policies and procedures. Key standards as identified in the intended outcomes sections of this report are inspected at least once every twelve months. Where key standards have not been inspected on this occasion they will have been inspected at the previous inspection. Reports in respect of previous inspections may be accessed via the Commissions website www.csci.org.uk What the service does well: Murrelle House provides a safe environment for people who have dementia and require nursing care. Information about each persons mental and physical health and safety needs is clearly recorded and kept up to date so as to ensure that all staff have sufficient information in order to best meet the needs of the people living in the home. Godden Lodge DS0000015536.V261234.R01.S.doc Version 5.0 Page 6 Where risks are identified such as risk of falls or developing pressure sores there was evidence that staff act promptly and seek advice from other healthcare professionals as required so as to minimise the risks to residents. Residents’ relatives are welcomed and are involved in the planning and review of care wherever this is appropriate. People living at the home receive a varied diet and are assisted to take meals according to their needs and wishes. What has improved since the last inspection? What they could do better: The storage of medicines, which are to be disposed of, must be reviewed so as to ensure that all medicines are stored safely and securely. The activities provided by the home could be improved and activities and stimulation should be made available when the activities coordinator is not on duty. The provision of hairdressing services should be more easily accessible to the residents living on Murrelle House. The communal areas could be made more comfortable and homely and more could be done so as to keep the house free from unpleasant odours. Please contact the provider for advice of actions taken in response to this Godden Lodge DS0000015536.V261234.R01.S.doc Version 5.0 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Godden Lodge DS0000015536.V261234.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 Godden Lodge DS0000015536.V261234.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 People are only admitted to the home following a comprehensive assessment of their mental health, nursing and general care needs has been carried out. EVIDENCE: Before a place is offered to any prospective resident a detailed and comprehensive assessment of their needs is carried out by one of the senior nursing staff. The assessment tool used is the Behavioural Assessment of Later Life (BASOLL), which is particularly suited to assessing the specific needs of older people who have dementia. Once this is completed the key areas of need are clearly identified so that the home can make a judgement as to whether these needs can be met. Godden Lodge DS0000015536.V261234.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 Information about each resident’s mental and physical health, and safety needs is clearly recorded so as to ensure that staff can best meet these needs. Staff ensure that residents receive the medicines, which have been prescribed for them at in a safe manner and at appropriate times in accordance with the homes policies and procedures and current relevant legislation. Staff treat residents living on Murrelle house with respect and dignity. EVIDENCE: Care plans were examined for five residents living on Murrelle House. Care plans were well written and included detailed information in respect of each individual’s mental and physical health needs. There was evidence that wherever it was possible that resident’s wishes were included in the plan of care and that residents relatives were consulted and provided with the opportunity to participate in the planning process. Assessments in respect of the risks to the people living at the home of sustaining injury, risk of falls and developing pressure sores are well Godden Lodge DS0000015536.V261234.R01.S.doc Version 5.0 Page 11 maintained and specific action to manage these risks and minimise the impact on residents is clearly recorded in each individuals care plans. There was evidence that where risks of falls had been identified that staff acted so as to minimise these risks and to investigate any underlying causes and seek medical intervention as necessary. It was positive to note that measures had been implemented so as to ensure that staff maintain records satisfactorily in respect of medicines administered to the people living in the home and that staff acted so as to ensure that residents receive the medicines which have been prescribed for them at the appropriate times. The arrangements for the storage of medicines which are to be disposed of is not satisfactory as medicines are stored in a container which may be accessed by staff and these medicines are not collected for disposal for up to three months. Staff were observed to act in an appropriate manner and to interact well with the people living in the home when assisting them with activities of living such as eating and drinking etc. Godden Lodge DS0000015536.V261234.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, 14 & 15 Murrelle House does not consistently provide stimulating activities for the people living there. Residents relatives are made to feel welcomed when they visit the home and are involved wherever it is appropriate are involved in the planning of care. Residents are not consistently assisted to exercise choice and control over their lives. Residents receive a varied diet and are supported at mealtimes according to their needs. EVIDENCE: It was reported that activities such as music and games are generally provided in the afternoons. There were no activities observed during the inspection. While staff were noted to act in a positive manner there was little in the way of stimulating activities provided when the activities coordinator was not on duty. Resident’s relatives are made to feel welcome when they visit the home. Godden Lodge DS0000015536.V261234.R01.S.doc Version 5.0 Page 13 It was noted on the second day of the inspection that residents who live on Murrelle House had to go to one of the other houses to access hairdressing services. As a result of this many residents refused this service and it took staff a considerable length of time to assist those who wished to have their hair cut to go to the other house. This practice was not in accordance with the wishes of the people living on Murrelle House. The serving of breakfast was observed on the second day of the inspection. Residents were offered a choice of cereals, toast and fruit and staff assisted residents in a caring and sensitive manner. Godden Lodge DS0000015536.V261234.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): 16 & 18 Staff practices do not generate complaints. Staff working on Murrelle House are trained and act in an appropriate manner so as to protect the people living there from harm or abuse. EVIDENCE: Records indicated tat there have been no complaints made since the last inspection. Staff working at the home receive training and up to date information in respect of the protection of vulnerable people living on Murrelle House. Staff were observed to act and treat residents in an appropriate manner and care plans included details of how best to manage displays of verbal and physical aggression. Godden Lodge DS0000015536.V261234.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): 19, 20 & 26 Murrelle House provides a well-maintained and safe environment for the people who live there. EVIDENCE: Murrelle House is well maintained and regular checks are carried out in relation to the premises and equipment so as to minimise risks to the safety of the residents who live there. A number of bedrooms have been redecorated since the last inspection and some new furniture and crockery had been purchased. It was reported that there were plans to improve the décor in the communal areas to provide a more homely environment for the people who live there. Some stale odours were detected on entering the house on both days of the inspection. However corridors and residents bedrooms were noted to be free from unpleasant odours. Godden Lodge DS0000015536.V261234.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 Staff are employed in sufficient numbers so as to meet the assessed needs of the people who live on Murrelle House. EVIDENCE: Staffing levels had been reviewed and increased since the last inspection and it was reported that this allowed staff more time to spend with residents and to provide a better standard of care. Staffing rotas indicated that staff did not work excessive hours without appropriate off duty time. At the time of this inspection the homes registered manager was on holiday and staff working at the home did not have access to the records in relation to the recruitment and training of staff. These standards will be assessed at the next inspection. Godden Lodge DS0000015536.V261234.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, 33, & 38 Murrelle House is generally managed so as to meet the needs of the people who live there, however routines and practices do not consistently reflect residents choices. Murrelle House is maintained so as to promote the safety of those live and work in, and those who visit the home. EVIDENCE: The day to day running of Murrelle House had improved since the last inspection, which improved the quality of life for those who live there. Some routines such as the provision of hairdressing services should be reviewed so as to best meet the needs and wishes of the people living at the home. Godden Lodge DS0000015536.V261234.R01.S.doc Version 5.0 Page 18 The home employs dedicated maintenance staff to assess and carry out repair as required. During this inspection the maintenance person was noted to visit each house to check for any problems and to deal with these promptly. No issues regarding health and safety were observed throughout the course of this inspection. Godden Lodge DS0000015536.V261234.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 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 2 X X X X X 2 STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X X 2 3 Godden Lodge DS0000015536.V261234.R01.S.doc Version 5.0 Page 20 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 OP9 Regulation 13(2) Requirement The registered persons must ensure that all medicines, including those which are to be disposed are stored in a safe manner so as to minimise the risk of mishandling. This requirement is outstanding from the previous inspection. The registered persons must ensure that a range of stimulating and occupational activities are provided at such times as meets the wishes of the people living at the home. This requirement is outstanding from the previous inspection. The registered persons must ensure that so far as it is practicable that residents are assisted to exercise control and choice over their lives and that the daily routines and practices are flexible so as to facilitate this. The registered persons must ensure that any unpleasant odours are dispelled promptly. DS0000015536.V261234.R01.S.doc Timescale for action 30/04/06 2 OP12 16(m) (n) 30/04/06 3 OP33OP14 16(m) (n) 30/04/06 4 OP26 16(2) (k) 30/04/06 Godden Lodge Version 5.0 Page 21 5 OP30OP37 OP29 17 Records in respect of the recruitment and training of staff must be made available for inspection upon request 30/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP20 Good Practice Recommendations The décor and furnishings in communal areas could be more homely in nature. Godden Lodge DS0000015536.V261234.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection South Essex Local Office 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 DS0000015536.V261234.R01.S.doc Version 5.0 Page 23 - 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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