Inspection on 22/09/05 for Gordon Lodge Nursing Home

This inspection was carried out on 22nd September 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 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 18/01/06

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 22nd September 2005 10:15 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.V252531.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. Gordon Lodge Nursing Home DS0000010948.V252531.R01.S.doc Version 5.0 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.V252531.R01.S.doc Version 5.0 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 28/2/05 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.V252531.R01.S.doc Version 5.0 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. Rekha Bhardwa Lead Inspector undertook the inspection. A total of 4.45hours was spent on the inspection process. The Inspector carried out a tour of each floor of the home, and inspected service user plans, staff files and maintenance records. The Inspector met all the service users at the home and spoke with 5 staff as part of the inspection process. At the time of the inspection there were 17 service users. The pre-inspection documentation completed by the home was also examined to inform the inspection. What the service does well: What has improved since the last inspection? What they could do better: Further work needs to be undertaken to ensure that there is a staff member on each shift who has received first aid training. Shortfalls in medication must be addressed, this includes ensuring that there is a record of all medication received into the home and recording the dates of when liquid medication has been opened. Discussions with the dispensing pharmacist must take place to ensure that sticky labels are not used on Medication Administration Records. Arrangements must be in place for the disposal of medication through controlled waste. Results of service users surveys must be published. Gordon Lodge Nursing Home DS0000010948.V252531.R01.S.doc Version 5.0 Page 6 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.V252531.R01.S.doc Version 5.0 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.V252531.R01.S.doc Version 5.0 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): 1, 3, 4, 5. The home does not provide intermediate care. The service users in the home are provided with information about the home and the services provided, so as to be clear about the services the home provides to meet their needs. Service users are assessed prior to admission to ensure that the home can meet their needs. Prospective service users and/ or their representatives are encouraged to visit the home in order to allow them to make an informed choice. EVIDENCE: The Statement of Purpose had been updated and a copy had been sent to the Commission. A Service User Guide was also available. The Registered Manager or a Senior Nurse undertakes all pre-admission assessments. Where service users have been referred by the PCT or Social Services a Needs Led Assessment is obtained beforehand. The documents viewed provided a clear picture of the service users needs. Gordon Lodge Nursing Home DS0000010948.V252531.R01.S.doc Version 5.0 Page 9 The home has its own assessment tool, which is based on a nursing model. Since the last inspection the home has developed a system, which, confirms in writing to the service user that the home is suitable of meeting the service user’s needs in respect of their health and welfare. This is undertaken by the deputy care manager who sends a letter to the potential service user. The Registered Manager is a trained mental health nurse and a general nurse. The senior nurse is also an Registered Mental Nurse and other staff in the home have received training in caring for service users with a mental illness or dementia. The Registered Manager said that whenever possible, prospective service users are encouraged to visit the home, and meet other service users and staff. If the service user were unable to visit the home, then their relative or representative would visit on their behalf. The prospective service user would also be sent a copy of the Service User Guide. Gordon Lodge Nursing Home DS0000010948.V252531.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 The health and personal care needs of service users had been identified and were being met. Care plans were being reviewed and updated. Shortfalls in completing fully bedrail assessments could potentially place service users at risk. Generally medications were being well managed, so as to ensure that service users medication needs are met. Shortfalls identified in relation to labels, dating liquid medications, receipts and disposal must be addressed to ensure service users safety. Service users were being treated with courtesy and respect. EVIDENCE: A sample of service users care plans were viewed during the course of the inspection. There was evidence that these were regularly reviewed and updated on a regular basis. Where service users are under the Care Programme Approach their needs are monitored by the Consultant Psychiatrist at Ealing Hospital. Gordon Lodge Nursing Home DS0000010948.V252531.R01.S.doc Version 5.0 Page 11 Specialist input from health care professionals are accessed via referrals from the GP, this includes the Tissue Viability Nurse, Community Dietician, Chiropodist, Optician, Consultant Psychiatrist, Community Psychiatric Nurse and other healthcare professionals. Where service users fall within the catchment area they continue with their own GP. Daily records were available and detailed the care provided. Service users health needs were identified and detailed in the service user plan. Assessments for moving and handling, risk of falling, pressure sore and nutritional screening were in place, with appropriate care plans in place to meet the identified needs. Continence assessments were not available and the Registered Manager stated that these would be put into place for those service users where continence had been identified as an issue. Bedrail assessments were available however the information contained in the assessments did not identify the reason why bedrails were required. The medication fridge temperatures were within the required range. The Controlled Drugs Register was viewed and found to be well recorded. The receipts of medication had not been recorded and the importance of ensuring that receipts of medication was discussed with the Registered Manager. A sample of medication administration records were viewed at random. The Inspector noted that the MAR sheets were not printed with the prescription instructions but that the dispensing pharmacist had attached labels with prescription instructions. This is not a permanent record as the label can be removed. It was agreed at the time of the inspection that this would be addressed with the supplying pharmacist. Liquid medications did not have the date of opening recorded. The Registered Manager was in the process of updating the medication procedure to reflect the changes in relation to the disposal of medication and was in the process of obtained a medication disposal bin. Staff were seen to address service users in a courteous manner. Service users who were able to speak to the Inspector indicated that they were well looked after. Gordon Lodge Nursing Home DS0000010948.V252531.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): 13,14 &15 Visiting is encouraged and this enhances the service users lives and maintains contact with their families and friends. Service users choices in their care and routines are respected within the service users capabilities. The meals in this home are good offering both choice and variety and catering for special dietary needs. EVIDENCE: The majority of service users spend time in the lounge area in the day. Some service users do spend time in their bedrooms. Service users and their representatives are provided with information on how to contact advocacy services through MIND, Age Concern and Alzheimer’s Concern. Relatives and friends were seen visiting service users. Visitors are discouraged from visiting during meal times to minimise disruption to service users. Representatives from the Catholic Church and the Church of England visit the home on a monthly basis. Gordon Lodge Nursing Home DS0000010948.V252531.R01.S.doc Version 5.0 Page 13 The Inspector observed the service users having their lunchtime meal. Where service users required assistance with feeding this was undertaken sensitively and in keeping with the service users needs. The service users appeared to be enjoying their lunch and those who could comment indicated that the food was good. A menu is available and the cook had been keeping records of the actual food served. Hot and cold snacks are offered throughout the day, along with hot and cold drinks. The cook also prepares diabetic and pureed diets. Gordon Lodge Nursing Home DS0000010948.V252531.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): 16,17 & 18 The home has a satisfactory complaints system with evidence that service users and representatives are listened to and acted upon. Service users rights are protected and service users are able to exercise their legal rights directly. Systems are in place for the protection of vulnerable adults, so as to protect service users from possible risk of harm or abuse. EVIDENCE: The home has a detailed complaints procedure, which is available in the Statement of Purpose and the Service User Guide. No complaints have been received by the home since the last inspection. Details on advocacy services are available in the home. This included MIND, Age Concern and Alzheimer’s Concern. The Registered Manager stated that service users representatives and their Social Workers also advocate on behalf of the service users. The Protection of Vulnerable Adults procedure was available and dovetailed with the Local Authority POVA documentation. The Registered Manager confirmed that staff had received training in POVA procedures. One POVA Gordon Lodge Nursing Home DS0000010948.V252531.R01.S.doc Version 5.0 Page 15 allegation was investigated by the London Borough of Ealing and was found to be unsubstantiated. Gordon Lodge Nursing Home DS0000010948.V252531.R01.S.doc Version 5.0 Page 16 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): 19,20,21, 22, 23, 24, 25 and 26. The home was clean and tidy and the environment was safe for the service users, this provides service users with a comfortable and safe environment for those living in the home and visiting. Equipment and adaptations to meet service users needs are in place. Systems were in place for the prevention of the spread of infection and were being adhered to. Thus safeguarding service users. EVIDENCE: A tour of the home was undertaken during the course of the inspection. The home was clean, warm and well presented throughout. Plans were in place to have the corridor carpets, and the hallway carpet in the extension replaced on the 23/9/05 along with four bedroom carpets. Gordon Lodge Nursing Home DS0000010948.V252531.R01.S.doc Version 5.0 Page 17 The home has an L shaped lounge and conservatory for the service users. There is a small garden, which can be accessed via the conservatory. 5 single bedrooms and 6 double bedrooms, the double bedrooms viewed had privacy curtains in place. A programme of routine decoration of the bedrooms and renewal and replacement of the furniture was in place. Bedrooms viewed were personalised with pictures, photographs, plants and personal items. As the home accommodates service users with dementia the front door is alarmed for safety purposes. A passenger lift is available and the Registered Manager informed the Inspector that a new bath for the first floor had been purchased and was to be fitted as part of the refurbishment of the bathroom. Suitable toilet and bathing facilities are available in he home. Toilets are located close to the lounge and the communal areas. The home was clean and odour free throughout. Gloves, aprons, soap and paper towels were available in the toilet and bathroom areas. Ongoing training on infection control was in place. The Inspector spoke with the laundry person on duty who confirmed that she was aware of the infection control procedure and how to handle soiled laundry. Gordon Lodge Nursing Home DS0000010948.V252531.R01.S.doc Version 5.0 Page 18 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): 27,28,29 & 30 The home was adequately staffed to meet the needs of the service users. Staff training is ongoing to ensure that staff have the skills to meet the needs of the service users. The vetting and recruitment practices were in place so as to safeguard service users. EVIDENCE: The staffing numbers for each shift are as follows: Morning: 2 Registered Nurses and two care assistants Afternoon: 2 Registered Nurses and two care assistants Night: 1 Registered Nurse and one care assistant Ancillary staff includes a cook, kitchen assistant, laundry person, cleaner and handy person. There are 5 care staff qualified to NVQ level 2 or above. Evidence of other training to include mandatory training sessions was seen and there is an ongoing investment in the training provision for staff. The staff employment files viewed contained the required information. Gordon Lodge Nursing Home DS0000010948.V252531.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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, 32, 33, 35, 36 & 38 The home is well managed and the Registered Manager has an open style of management. Meeting the needs of service users is a high priority for the staff team and the Registered Provider. The staff are approachable, professional and are skilled in caring for the service users. Overall systems for the management of health and safety were in place with the exception of having a staff member on each shift who is qualified in first aid. This potentially places service users at risk. EVIDENCE: Gordon Lodge Nursing Home DS0000010948.V252531.R01.S.doc Version 5.0 Page 20 The Registered Manager is also one of the Registered Providers. She is a qualified Registered General Nurse and a Registered Mental Nurse. The Registered Manager has a Diploma In Management Studies and has been running Gordon Lodge for over ten years. The home is well managed; the Registered Manager has an open style of management and leads by example. Result s of service users surveys had not been published and made available to current and prospective service users or the Commission. This was a requirement from the last inspection and has been restated in this report. Small amounts of money are managed by the Registered Manager on behalf of some service users. The Deputy Manager informed the Inspector that where personal allowances are provided via the Local Authority the receipts of any expenditure are sent to the Local Authority in order that the home is forwarded the money that has been spent. The Registered Manager maintains written records of all transactions. Where possible service users representatives are encouraged to manage personal finances. Generally records were well maintained. Shortfalls have been identified under the Health and Personal Care section of this report and requirements have been set accordingly. Servicing records were viewed at random and were up to date this included weekly hot water temperature checks. Generic and specific risk assessments were available. The Inspector noted that only the Registered Manager and one Registered General Nurse had received first aid training. It was discussed the need to have a staff member on each shift who had been trained in first aid. It was recommended at the inspection that the Registered Manager develop a training matrix, which would indicate what training had taken place and what training staff needed to undertake. Gordon Lodge Nursing Home DS0000010948.V252531.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 3 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 3 2 X 3 X 3 2 Gordon Lodge Nursing Home DS0000010948.V252531.R01.S.doc Version 5.0 Page 22 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 2 Standard OP8 OP8 Regulation 13(4)(7) 12(1) Requirement Bed rail assessments must clearly record the reason why they are in use. Continence assessments must be in place for those service users where incontinence has been identified as a need. Labels on Medication Administration Records must not be used. A system for the safe disposal of medication must be in place. The policy and procedure in relation to medication must be updated to reflect this. A record of all medication received into the home must be maintained. The results of service users’ surveys must be published and made available to current and prospective service users, their representatives and other interested parties including the CSCI. (timescale of 31/5/05 not met) The Registered Person must ensure that the home complies with the Health and Safety (First DS0000010948.V252531.R01.S.doc Timescale for action 31/10/05 31/10/05 3 4 OP9 OP9 13(2) 13(2) 31/10/05 31/10/05 5 6 OP9 OP33 13(2) 24(1)(a)( b)(2)(3) 31/10/05 31/10/05 7 OP38 13(4) 31/12/05 Gordon Lodge Nursing Home Version 5.0 Page 23 Aid) Regulations 1992. A person with a recognised First Aid certificate must be on duty on each shift. 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 OP38 Good Practice Recommendations It is strongly recommended that the Registered Manager have a training matrix in place. Gordon Lodge Nursing Home DS0000010948.V252531.R01.S.doc Version 5.0 Page 24 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.V252531.R01.S.doc Version 5.0 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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