Inspection on 10/07/07 for Gordon Lodge Nursing Home

This inspection was carried out on 10th July 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

Gordon Lodge Nursing Home 31/10/06

Gordon Lodge Nursing Home 18/01/06

Gordon Lodge Nursing Home 22/09/05

Gordon Lodge Nursing Home 28/02/05

Gordon Lodge Nursing Home 08/09/04

Gordon Lodge Nursing Home 09/03/04

Gordon Lodge Nursing Home 24/06/03

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

CARE HOMES FOR OLDER PEOPLE Gordon Lodge Nursing Home 102 Gordon Road Ealing London W13 8PS Lead Inspector Clare Henderson-Roe Key Unannounced Inspection 10:45 10th & 19th July 2007 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 Gordon Lodge Nursing Home DS0000010948.V341088.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. Gordon Lodge Nursing Home DS0000010948.V341088.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Gordon Lodge Nursing Home Address 102 Gordon Road Ealing London W13 8PS 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) 020 8997 8967 020 8997 3548 gordonlodge-home@hotmail.com Mrs Maudlyn Cecilia Andall Mrs Maudlyn Cecilia Andall Care Home 17 Category(ies) of Dementia (0), Mental Disorder, excluding registration, with number learning disability or dementia - over 65 years of of places age (0), Old age, not falling within any other category (0), Physical disability (0), Physical disability over 65 years of age (0) Gordon Lodge Nursing Home DS0000010948.V341088.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service Users to indicate up to 7 MD(E)`s and up to 17 Service Users in total 31st October 2006 Date of last inspection Brief Description of the Service: Gordon Lodge Nursing Home is registered to provide care for seventeen service users. It is a stand alone home in an attractive, detached house in West Ealing close to the local amenities in West Ealing and Ealing Broadway. The home provides a warm and comfortable environment consisting of five single and six double bedrooms. There are five bathrooms and a passenger lift. Hand washing facilities are available in each service users bedroom. The home has a medium sized lounge and dining area with an attached Victorian conservatory. There is an attractive garden to the rear of the building that can be accessed via the conservatory. The fees range from £550 to £650 per week. At the time of the inspection 16 service users were accommodated at the home. Gordon Lodge Nursing Home DS0000010948.V341088.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the regulatory process. A total of 7 hours was spent on the inspection process. The Inspector carried out a tour of the home, and service user plans, medication records, staff rosters, staff records, financial & administration records and maintenance & servicing records were viewed. 4 residents, 4 staff and 2 visitors were spoken with as part of the inspection process. The CSCI Annual Quality Assurance Assessment document (AQAA) completed by the home has been used to inform this report. Only 1 of the 27 CSCI comment cards sent to the home and to residents’ representatives has been received back by CSCI, thus limiting inclusion of comments from these sources. What the service does well: What has improved since the last inspection? There has been an improvement in the completion of service user plan documentation and the involvement of residents and/or their representatives. The medications policy has been updated in line with current legislation and good practice guidance. Gordon Lodge Nursing Home DS0000010948.V341088.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Gordon Lodge Nursing Home DS0000010948.V341088.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Gordon Lodge Nursing Home DS0000010948.V341088.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 & 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are fully assessed prior to admission, thus the home ensures they are able to meet each persons needs. Prospective residents and their families can visit the home prior to admission, thus enabling them to make an informed decision about moving to the home. EVIDENCE: The home has a comprehensive pre-admission assessment document that provides a good picture of the resident and their needs. Those viewed had been fully completed. A copy of the Social Services assessment for each prospective resident is also obtained by the home. 2 visitors spoken with said that they had been able to visit the home prior to their relative being admitted and were shown around and any questions they had were answered. Gordon Lodge Nursing Home DS0000010948.V341088.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service user plans are well completed, thus providing staff with the information required to meet each resident’s needs. There is evidence of input from healthcare professionals, thus managing residents healthcare needs effectively. Although medication is being managed, shortfalls identified could place residents at risk. Staff care for residents in a gentle and professional manner, respecting their privacy and dignity. EVIDENCE: The Inspector viewed 3 service user plans. These were well completed and personalised, giving a good picture of each residents’ needs, to include mental health needs. There was evidence of monthly reviews taking place, and of input from representatives. For one resident recently admitted to the home further work on the care plans was to be done. Risk assessments for falls were in place and these are updated monthly and following any falls. Gordon Lodge Nursing Home DS0000010948.V341088.R01.S.doc Version 5.2 Page 10 Assessments for moving & handling to include identification of any specific equipment to be used were in place. Nutritional assessments had been completed and where a problem had been identified, a care plan for nutrition had been formulated. Pressure sore risk assessments were in place. One resident had a wound and the wound care documentation was comprehensive and up to date. Pressure relieving equipment was available and in use. The home uses the Primary Care Trust continence assessment and was awaiting a further supply of the documents. Care plans to address continence needs had been completed. There was evidence of input from the tissue viability nurse, GP, physiotherapist and other healthcare professionals. The Inspector viewed the medication management. The home has recently introduced a monitored dosage system (mds) and the majority of medications are supplied in blister packs. All medication receipts and disposals had been signed for. Some gaps in signing for administration were noted, and on checking the stock the medications had been given. For medication with a variable dose the actual number of tablets given had not been recorded. Liquid medications had been dated when opened. Some of the entries on the medication administration record (MAR) charts had been handwritten and the Inspector strongly recommended that these entries be checked and signed by two registered nurses as good practice. Information regarding resident allergies had been added to the MAR charts by the second day of inspection. The minimum and maximum fridge temperatures were not being recorded. This is a repeat finding. A form to address this had been formulated by the second day of inspection. The room temperature was not being recorded and this is important to ensure the room temperature stays within safe range. The medications policy still required updating in line with current legislation and good practice guidance. A copy of the updated policy has since been forwarded to CSCI. Controlled drugs records were accurate and up to date and all medications were being stored securely in the home. Staff were seen caring for residents in a gentle, caring and professional manner and the residents appeared content. Bedrooms viewed were personalised and looked homely. Residents’ personal clothing is labelled and residents were well groomed and dressed, reflecting individuality. Staff speak with residents using their preferred term of address. The one comment card received by CSCI was very positive about the care provision in the home. Gordon Lodge Nursing Home DS0000010948.V341088.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides activities to meet the needs and abilities of the residents. The home has an open visiting policy, thus encouraging people to maintain contact with family and friends. Information regarding advocacy services was available, thus peoples right to individual representation is respected. The food provision in the home is good, offering variety and choice, thus meeting peoples’ individual needs. EVIDENCE: Staff engage residents in various activities and there is an activities programme available. Outings are also arranged to go shopping, to the theatre or for a walk. A pianist now attends the home every fortnight to play live music for the residents. Staff were seen playing board games with the residents, who were enjoying the activity. The mobile library visits every 2 weeks. The home is planning to provide more outings and also to recruit an activities coordinator, which will enhance the activities provision. Gordon Lodge Nursing Home DS0000010948.V341088.R01.S.doc Version 5.2 Page 12 The home has an open visiting policy and visiting is encouraged. Residents can receive visitors in their own bedroom or in one of the communal areas, as they so wish. The visitors spoken with said that they are made welcome at the home and are offered refreshments. The home has information on display for a company who provides advocacy services. Age Concern and the Ealing Advocacy Service were also discussed with the Deputy Manager. There were no issues with advocacy at the time of inspection. The Inspector viewed the kitchen, which was clean and tidy. The cleaning, temperature and meal choice records had not been completed for some months and this is a repeat finding. On the second day of inspection the cook had recommenced completing these records. The Environmental Health Inspection carried out in March 2007 had identified a shortfall and this had not yet been addressed. The importance of maintaining records up to date was discussed with the cook and the management of the home. Stocks of fresh, frozen dried and tinned foodstuffs were available and items viewed were within their ‘use by’ dates. The Inspector sampled the lunch on the first day of inspection and the meal was tasty and well presented. Residents were seen enjoying their lunch and staff were available to serve and assist them as needed. The menu changes regularly and residents preferences are considered when drawing up the menus. Snacks and drinks are available throughout the 24 hour period. Gordon Lodge Nursing Home DS0000010948.V341088.R01.S.doc Version 5.2 Page 13 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 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has policies and procedures in place for the management of complaints and adult protection issues, and these are followed, thus safeguarding the residents. EVIDENCE: The home has a clear complaints procedure in display in the home. The Deputy Manager said that should they receive a complaint action would be taken immediately to address it. There have been no complaints since the last inspection. The home has procedures in place for POVA and also follows the Ealing Safeguarding Adults procedures. Staff had received training and were clear to report any concerns. Policies and procedures are in place for the management of aggressive and bullying behaviours. Gordon Lodge Nursing Home DS0000010948.V341088.R01.S.doc Version 5.2 Page 14 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 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is being well maintained, thus providing a clean, homely and safe environment for residents to live in. Procedures are in place for infection control and these are practiced, thus minimising the risk of infection. EVIDENCE: The Inspector carried out a tour of the home. The home is well maintained and the décor and furnishings are satisfactory, with evidence of ongoing redecoration and refurbishment. There are plans to change one bath facility with limited access for residents into an assisted shower room. Radiators have guards in place and there were no environmental shortfalls identified. Bedrooms are personalised, have suitable locks and each resident has a lockable space for personal items. There are profiling beds in some rooms to meet the needs of the resident. The flooring in the bedrooms is appropriate to the individual needs of each resident. There is a well-maintained rear garden with easy access for the residents. The home provides a bright, homely place Gordon Lodge Nursing Home DS0000010948.V341088.R01.S.doc Version 5.2 Page 15 for residents to live in. The AQAA evidenced plans for upgrading the premises in the future. On the first day of inspection the tumble dryer was out of order. Action had been taken to identify the problem and order a part, and alternative drying arrangements were in place. This has since been repaired. The washing machine has a hot wash programme for disinfection purposes if required. Protective clothing to include gloves and aprons was available. The home was clean, bright and airy and smelled fresh throughout. Gordon Lodge Nursing Home DS0000010948.V341088.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is appropriately staffed thus ensuring the needs of the residents can be met at all times. Training provision is good, thus providing staff with the skills and knowledge to care effectively for the residents. Systems are in place for the vetting and recruitment of staff, thus safeguarding residents. EVIDENCE: The home was being appropriately staffed to meet the needs of the residents and also to keep the home clean and well maintained throughout. The staffing roster reflects all of the staff team for the home. The Registered Manager said that she ensures that there are sufficient numbers of staff on duty at all times so that any situations that may occur can be effectively managed, for example, an unexpected hospital visit. Two of the care staff are qualified to NVQ level 2 in care with a further 5 undertaking this training, and once they have completed it this will bring the percentage of staff with NVQ in care level 2 to over 50 . One Inspector viewed staff employment records and with the exception of one reference these included all the information required under Care Home Regulations 2001. Following the inspection evidence that 3 references had been taken up for the member of staff was forwarded to CSCI. Gordon Lodge Nursing Home DS0000010948.V341088.R01.S.doc Version 5.2 Page 17 The home has in place a staff induction and foundation programme that meets the Skills for Care common induction standards. One member of staff spoken with said that they were completing the induction booklet and had a mentor to ensure that they completed each section in full. All staff also undergo a general induction and orientation programme on commencing work at the home. Staff also receive training in topics relevant to the specific needs of the residents. Gordon Lodge Nursing Home DS0000010948.V341088.R01.S.doc Version 5.2 Page 18 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, 33, 35 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager has the qualifications and experience to managed the home and does so effectively. Systems for quality assurance are in place, however regular auditing does not always take place, thus practice review is not being effectively monitored. Monies held on behalf of residents are being well managed and securely stored, thus safeguarding them. Systems for the management of health and safety throughout the home are good, thus safeguarding residents, staff and visitors. EVIDENCE: The Registered Manager is a registered nurse with general and mental health qualifications. She also has a diploma in management and undertakes periodic training relevant to her nursing and management roles. The Registered Gordon Lodge Nursing Home DS0000010948.V341088.R01.S.doc Version 5.2 Page 19 Manager is also the Registered Provider. The Deputy Manager is currently undertaking the Registered Managers Award, NVQ level 4. The home is being well managed and it was clear that the Registered Manager values her staff team and provides good leadership. The home has a system for quality assurance in place and the Deputy Manager said that he completes the documentation. The introduction of audits of the home to include medications and kitchen records was discussed, so that any shortfalls or poor practices are identified and can be promptly addressed. Satisfaction surveys are done annually to include relatives, GP’s, visitors, staff and other visiting healthcare professionals, plus the residents who are able to join in a survey. The results are used to implement changes in the home. The Inspector viewed several of the surveys and the comments were very positive. The need to collate the results and publish them, providing a copy to CSCI was discussed with the management. Policies and procedures are updated in line with changes in legislation and good practice. The home holds personal monies on behalf of 3 residents. A clear record of income and expenditure is kept for each individual. A receipts book is used for all monies received. The Inspector checked the money balances against the records and all were correct and up to date. The Inspector viewed some of the maintenance and servicing records and those viewed were up to date. Some of the records could not be found on the first day, however these were readily available on the second day of inspection. The fire risk assessment was up to date. Fire drills are carried out for day and night staff and clear records are kept. Hot water temperature records were up to date. Staff had received training in health & safety topics to include fire safety, moving & handling, food hygiene and infection control. The home uses DVDs from a company who state the training packages meet the training requirements under the areas of health & safety. A qualified instructor provides the fire safety training and the Registered Manager said she would ensure that the trainer providing the practical skills training for moving & handling is up to date as a trainer for this topic. No health & safety issues were identified during the inspection and overall health & safety is being well managed at the home. Gordon Lodge Nursing Home DS0000010948.V341088.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X 3 N/A 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 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 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 X 2 X 3 X X 3 Gordon Lodge Nursing Home DS0000010948.V341088.R01.S.doc Version 5.2 Page 21 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 Medicines must be recorded accurately when administered. (previous timescales of 01/09/06 & 15/12/06 not met) The home must record the minimum and maximum temperature of the fridge. (previous timescales of 01/09/06 & 15/12/06 not met) Where a variable dose of medication is prescribed the actual dose given must be recorded, so that the records accurately reflect administration. Records of cleaning schedules and fridge temperatures must be available and up to date. (previous timescale of 15/12/06 not met) Records of the food provided for service users must be maintained and kept up to date. previous timescale of 15/12/06 not met) There must be an effective auditing system in place so that any shortfalls in practice are DS0000010948.V341088.R01.S.doc Timescale for action 20/07/07 2. OP9 13(2) 20/07/07 3. OP9 13(2) 20/07/07 4. OP15 13(3) 20/07/07 5. OP15 17(2) 20/07/07 6. OP33 24 10/08/07 Gordon Lodge Nursing Home Version 5.2 Page 22 identified promptly and action taken to address them, to ensure all aspects of the home and care provision are of a consistent good standard. 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 OP9 Good Practice Recommendations Any handwritten entries on MAR charts should be checked and initialled by two registered nurses as good practice. Gordon Lodge Nursing Home DS0000010948.V341088.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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 - 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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