Inspection on 18/01/06 for Gordon Lodge Nursing Home

This inspection was carried out on 18th January 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

Gordon Lodge Nursing Home 10/07/07

Gordon Lodge Nursing Home 31/10/06

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 Mrs Rekha Bhardwa Unannounced Inspection 18th January 2006 09:45 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 Gordon Lodge Nursing Home DS0000010948.V275330.R01.S.doc Version 5.1 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.V275330.R01.S.doc Version 5.1 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 Mrs Maudlyn Cecilia Andall Mrs Cecilia Maudlyn 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.V275330.R01.S.doc Version 5.1 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 22nd September 2005 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. Gordon Lodge Nursing Home DS0000010948.V275330.R01.S.doc Version 5.1 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 5.30hours was spent on the inspection process. The Inspector carried out a tour of the home, inspected service user plans, servicing records, medication records and staff records. The purpose of this inspection was to follow up the requirements and one recommendation from the last inspection, and to view some additional standards. The majority of key standards were viewed at the last inspection and it is recommended that this report be read in conjunction with the last report to gain full inspection information for the home. Several service users, 5 staff and one visitor were spoken with as part of the inspection process. It must be acknowledged that it is not always possible to ascertain the views of service users with dementia and mental illness. The inspector was informed by the Registered Manager that since the last inspection she now employs a retired Registered Nurse to undertake training with the staff, this includes training around clinical issues which may effect service users. What the service does well: What has improved since the last inspection? What they could do better: The medication policy and procedure must be reviewed to include drug errors. Shortfalls in recording the dates of opening on liquid medications and eye drops must be addressed. An activities programme based on the needs and Gordon Lodge Nursing Home DS0000010948.V275330.R01.S.doc Version 5.1 Page 6 preferences of this service group must be in place. The activities person must receive training in this area. 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. Gordon Lodge Nursing Home DS0000010948.V275330.R01.S.doc Version 5.1 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.V275330.R01.S.doc Version 5.1 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 the following standard(s): 2 All service users have a written agreement/contract, so as to be clear about the services the home provides to meet their needs. EVIDENCE: Both service users files viewed contained information regarding the terms and conditions of stay at the home. One had been signed by the Social Worker the other had been signed by the service users representative and the Registered Provider. Gordon Lodge Nursing Home DS0000010948.V275330.R01.S.doc Version 5.1 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 the following standard(s): 7,8 & 9 The service user plans are generally well formulated and monthly updates are taking place to ensure that information in relation to service users is up to date. Shortfalls identified should be easy to address. Medications are generally well managed in the home, however shortfalls identified could potentially place service users at risk. EVIDENCE: Two service user plans were viewed at this inspection. Both provided detailed information on how the assessed needs of the service users were to be met. Regular reviews were taking place and service user plans were being updated if needed following the review. Not all service user plans had been signed and dated by the Registered Nurse completing the plan. A comprehensive assessment document is used by the home to assess the service users needs. For one service user the section under working, playing and social care had not been completed. Gordon Lodge Nursing Home DS0000010948.V275330.R01.S.doc Version 5.1 Page 10 Both files viewed contained continence assessments, risk of falling assessment, moving and handling assessments, pressure sore risk assessments and nutritional assessments. It was recommended at the time of the inspection that the type pf equipment to be used for the service user be recorded on the moving and handling assessment. There was evidence in the files viewed of service users being able to access NHS services; this included the GP, Consultant Psychiatrist, Dentist, Optician and dietician. Daily record documentation is completed by the Registered Nurses on duty for each service user. Samples viewed were well recorded. The Deputy Manager stated that further work had been undertaken with the Registered Nurses to ensure that the bedrail assessments identified the reasons for the use of the bedrails. Bedrail assessments will be reviewed in detail at the next inspection. On the second day of the inspection the Inspector viewed samples of medication administration records and medication systems. The medication policy and procedure had been updated since the last inspection but did not cover drug errors. New medication waste disposal systems were in place. The home uses the Monitored Dosage System. Liquid medications and eye drops did not have the date of opening recorded. Only Registered Nurses administer medication, as Gordon Lodge is a nursing home. Gordon Lodge Nursing Home DS0000010948.V275330.R01.S.doc Version 5.1 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 the following standard(s): 12 Social activities are in place but these are not in accordance with service users wishes and assessed needs. EVIDENCE: The home employs an activities person from 09.30am to 12.30pm Monday to Friday. On the first day of the inspection the activities records were not available for inspection. In the pre-admission assessment document viewed for one service user there is a heading titled ‘working and playing/social ‘ this had not been completed. It was not clear what activities were available for service users. No activities programme was displayed. The Inspector spoke with the activities person; the types of activities on offer are exercises, skittles and reading. It was not clear whether these activities were based on the assessed needs and preferences of all service users. It was discussed with the Registered Manager the need to have an activities programme, which was wide ranging and would benefit the service users. It was also discussed the need to have the activities person undertake training in this area in order that the specialist needs of the service users and to ensure that social/leisure needs of service users are assessed. Gordon Lodge Nursing Home DS0000010948.V275330.R01.S.doc Version 5.1 Page 12 Some of the service users who spoke with the Inspector stated that they enjoyed the activities that they participated in but would like to see more variety Gordon Lodge Nursing Home DS0000010948.V275330.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None EVIDENCE: All three standards were all viewed and met at the last inspection. The Registered Manager reported no complaints had been received since the last inspection and that there had been no adult protection issues. Gordon Lodge Nursing Home DS0000010948.V275330.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 The standard of the environment within this home is good, providing service users with a homely place to live. EVIDENCE: The Inspector undertook a brief tour of the home. The home was clean and hygienic. Rooms were personalised and in a good state of décor. There is an ongoing programme of redecoration and renewal of furniture and carpets. Since the last inspection carpets have been changed in the ground floor corridor and the first floor corridor. There have been no changes in the laundry management since the last inspection. Gordon Lodge Nursing Home DS0000010948.V275330.R01.S.doc Version 5.1 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 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 & 29 The home is appropriately staffed to meet the needs of the current service users. The vetting and recruitment practices are in place, thus safeguarding service users. EVIDENCE: At the time of the inspection the home was staffed to meet the assessed needs of the service users. The Registered Manager keeps staffing levels under review in line with the service users dependencies. The Inspector viewed two sets of staff employment records. Both contained the information as require by Schedule 2 of The Care Homes Regulations 2001. Gordon Lodge Nursing Home DS0000010948.V275330.R01.S.doc Version 5.1 Page 16 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): 35,36 & 38 Staff receive supervision, thus promoting communication and review of practice. Overall, systems for the management of health and safety throughout the home are good, thus safeguarding service users, staff and visitors. EVIDENCE: The Deputy Manager stated that the business accounts for the home had been sent to the accountant for auditing. Once this had been completed a copy of the audited accounts would be sent to the CSCI. The Registered Manager stated that a system of staff supervision is in place. Supervision records were available and had been signed by the supervisee. Gordon Lodge Nursing Home DS0000010948.V275330.R01.S.doc Version 5.1 Page 17 Servicing records and maintenance record were viewed at random and were found to be well recorded. Fire drills had been undertaken for staff on 13th January 2006. Training records viewed indicated that staff were undertaking mandatory training. The Registered Manager had developed a training matrix since the last inspection. Gordon Lodge Nursing Home DS0000010948.V275330.R01.S.doc Version 5.1 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 x 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x x 3 X 3 x 3 Gordon Lodge Nursing Home DS0000010948.V275330.R01.S.doc Version 5.1 Page 19 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 OP7 Regulation 5 Requirement Service users plans must be signed and dated. Records maintained by Registered Nurses must be maintained in line with the Nursing and Midwifery guidance on records and record keeping. All assessment documentation to include social and leisure needs must be completed in full. Moving and handling assessments must include the details of the specific equipment that is to be used. Bed rail assessments must clearly record the reason why they are in use. (not assessed at this inspection, previous timescale of 31/10/05 to be reviewed at next inspection) Timescale for action 17/02/06 2 OP8 13(5) 17/02/06 3 OP8 13(4)(7) 01/03/06 4 5 6 OP9 OP9 OP12 13(2) 13(2) 12(2,3) (4)16(2) The medication policy and 01/03/06 procedure must include details of medication errors. The dates of opening must be 17/02/06 recorded on eye drops and liquid medications. 31/03/06 The Registered Manager must ensure that activities at the DS0000010948.V275330.R01.S.doc Version 5.1 Page 20 Gordon Lodge Nursing Home (m) home be reviewed to demonstrate that service users have opportunity to exercise choice with respect to leisure and social activities. The home must provide individual and group activities that meet the assessed needs of individual service users. 7 OP12 18 The activities person must undertake training in relation to activities provision. 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. Refer to Standard Good Practice Recommendations Gordon Lodge Nursing Home DS0000010948.V275330.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection West London Area Office 58 Uxbridge Road Ealing London W5 2ST 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 Gordon Lodge Nursing Home DS0000010948.V275330.R01.S.doc Version 5.1 Page 22 - 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!