Inspection on 06/10/05 for Grace Lodge

This inspection was carried out on 6th October 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

Grace Lodge 03/04/07

Grace Lodge 22/12/04

Grace Lodge 05/10/04

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

CARE HOMES FOR OLDER PEOPLE Grace Lodge Grace Lodge 4 Manor Road South Hinchley Wood Esher Surrey KT10 0QL Lead Inspector Susan McBriarty Unannounced Inspection 6th October 2005 10:00 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 Grace Lodge DS0000013654.V257329.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. Grace Lodge DS0000013654.V257329.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Grace Lodge Address Grace Lodge 4 Manor Road South Hinchley Wood Esher Surrey KT10 0QL 020 8398 0580 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) Mr Vikram Thakur Mr Vikram Thakur Care Home 15 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (15), of places Sensory impairment (1) Grace Lodge DS0000013654.V257329.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The age/age range of the persons to be accommodated will be: OVER 65 YEARS OF AGE, UP TO ONE OF WHOM MAY BE IN THE CATEGORY DE(E) 1 named person over 65 years of age may be accommodated who is in the category SI(E) 11th July 2005 Date of last inspection Brief Description of the Service: Grace Lodge is a detached property, located approximately two miles from Esher town centre. The property provides two sitting rooms, conservatory and dining room. The home has a mature garden which surrounds the rear of the house. The home has eleven single bedrooms and two shared bedrooms. Nine of the bedrooms have en-suite toilets. A lift facility is provided to enable service users to gain access to the first floor bedrooms and bathroom. The home has ample car parking space. Grace Lodge DS0000013654.V257329.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, the second for 2005 – 2006. The Inspector spoke with a visiting District Nurse, two residents, one member of the care staff and the owners. During the inspection a number of documents were sampled including staff personnel files, medication administration records, financial records and the outcome of a quality assurance audit. The Inspector wishes to extend their appreciation for their welcome to the home and the assistance offered during the inspection. What the service does well: What has improved since the last inspection? The home has sought to meet the requirements made at the last inspection. There has been some delay as the home has been subject to two floods over a period of two days caused by severe weather conditions. The proprietor has also been moving their internal office space and updating the information held by the home. In the interim the home has sought specialist advice regarding the provision of safety devices for the internal doors and has sourced dispensers for the provision of paper towels. The home was seeking paper towel dispensers that would not detract from the homely feel of Grace Lodge. These additional safety and hygiene items were expected to be in place shortly. Grace Lodge DS0000013654.V257329.R01.S.doc Version 5.0 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. Grace Lodge DS0000013654.V257329.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 Grace Lodge DS0000013654.V257329.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): EVIDENCE: Standards 1,2,3,4 and 5 were assessed during the inspection of 11th July 2005. Standard 6 does not apply. The requirement made on the 11th July 2005, that the statement of purpose be updated had not been met. The statement of purpose is well written and requirement made was with regard to specified information provided by the home. The proprietor had been moving office and updating all their information, this process had delayed the completion of the requirement. A further requirement was agreed enabling an extension for completion of the update. Grace Lodge DS0000013654.V257329.R01.S.doc Version 5.0 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): 9 The home has policies and procedures in place to enable the administration of medication and the safeguarding of residents. EVIDENCE: Standards 7,8,10 and 11 were assessed during the inspection of the 11th July 2005. The requirement made at the last inspection, that risk assessments be reviewed, updated and placed on file had been met. The home had a robust medication administration procedure. The Inspector sampled the medication administration records and found no gaps or errors. The files sampled had photographs of the resident, basic details regarding their medication. The home had also provided information within the file regarding some regularly prescribed medications and their use. The home had information available for staff to pass to ambulance staff and or families should a resident require admission to hospital. The information provided was found by the Inspector to contain the details required by hospitals on admission. Specified staff members had received training in the administration of medication. Grace Lodge DS0000013654.V257329.R01.S.doc Version 5.0 Page 10 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 The home has regard for the needs of the residents. EVIDENCE: Standards 14 and 15 were assessed during the inspection of the 11th July 2005. The Inspector spoke with two residents, the proprietor and proposed manager. The home is seeking to provide a more inclusive approach to the provision of activities. The home is able to meet the cultural needs of some others for example; Muslim, Hindu, Sikh and Christian. The majority of residents, at the time of the inspection, were white British. The proprietor informed the inspector that they are considering the provision of a regular newsletter to keep the residents, their relatives and others informed of what they do and what they plan to do. At present the home provides a range of regular activities including bingo, listening tapes, access to a PAT dog and sing-a-long sessions. The home also provides an impromptu approach to activities dependent on the needs and wishes of the residents. Additional activities had included barbeques and afternoon teas. The Inspector was informed that the home was also considering the provision of a written programme of activities reflecting the work that they are doing. The CSCI Grace Lodge DS0000013654.V257329.R01.S.doc Version 5.0 Page 11 supports the view of the home regarding the provision of a written activities programme. Family and friends are able to visit the home at a time suitable for them, within reason. The residents spoken with discussed the support of staff, which they felt to be good and the support they were able to give each other including any new residents entering the home. The Inspector made observations during the day including; staff members making welcome family members of residents to the home including children it was clear that there was a good relationship between staff and visiting families. The Inspector met with a local District Nurse who attends the home on a regular basis. The District Nurse informed the Inspector that the home calls on their service appropriately ensuring the nursing needs of the residents are met. The District Nurse also informed the Inspector that they had a good relationship with the home. Grace Lodge DS0000013654.V257329.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were assessed during the inspection of the 11th July 2005. Grace Lodge DS0000013654.V257329.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were assessed during the inspection of the 11th July 2005. The requirements made during the inspection were in hand. The leak in the bathroom was, on investigation, found not to be a leak but water pooling after the shower had been used. It was found that staff placed the curtain outside the cubicle causing water to pool on the floor. The action taken by the staff was to ensure the comfort of residents and to enable the staff member to maintain the dignity of residents while offering personal care. The wall has been taken back and the home is awaiting the return of the builder to complete the required work. Grace Lodge DS0000013654.V257329.R01.S.doc Version 5.0 Page 14 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 employs care staff and ancillary staff to meet the residents’ needs. Recruitment and training procedures met the standards. EVIDENCE: The Inspector was provided with a copy of the staff rota from 1st to the 7th October 2005. The rota shows three care staff including two senior carers, a cleaner and a cook on duty each morning and three care staff on duty each afternoon. At night the home has one waking staff, one sleep-in and one on call for emergencies. Of the six care staff employed at the home two have the equivalent of the National Vocational Qualification (NVQ) Level 2, both of whom are working toward the Level 3. A third has the Diploma in Health and Social Care the home was seeking confirmation that the Diploma was equivalent or higher than the NVQ Level 2. Should confirmation be received that the Diploma is equivalent of higher the home will have met the target of 50 of staff being qualified by 2005. The Inspector sampled staff personnel files and found the home met the standard. Criminal Record Bureau (CRB) checks were held separately from the personnel files. The files sampled by the Inspector showed that staff members had received appropriate training; for example the protection of vulnerable adults, induction, manual handling and medication administration. The home seeks to ensure that they can safeguard residents through regular staff training. Grace Lodge DS0000013654.V257329.R01.S.doc Version 5.0 Page 15 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): 31,32,33,34,35,36, 38 Further work is required to ensure that the home meets all the standards, the work required was in hand at the time of the inspection on the 6th October 2005. EVIDENCE: The requirements made at the inspection on the 11th July were in hand. The home has reviewed the provision of paper towels and has been seeking appropriate alternatives. The proprietor reported that the home wanted to ensure that the dispenser did not detract from the homely feel of Grace Lodge. The application for proposed manager had been delayed by the home. The proprietor informed the Inspector that they wanted to ensure that the required qualifying training had been completed and that the registered manager applicant was fully qualified before formally taking up the post. Grace Lodge DS0000013654.V257329.R01.S.doc Version 5.0 Page 16 The proprietor is currently the registered manager and has a degree in Business Studies and has undertaken the course in Management and Care in Private and Voluntary Homes. The home is a small family run business and the proprietor and proposed manager are on site each day and contactable in any emergency. The home had not collated the information available in order to provide an overall development or business plan. The Inspector did evidence planned building/repair work and was given a copy of the homes last audited accounts. Insurance cover was up to date. Two bedrooms had been flooded since the inspection on the 11th July. The floods had been caused by severe weather conditions. The specified residents affected were being provided with alternative short-term accommodation whilst the areas dry out and are redecorated. The flood had also delayed other work within the home. The fire doors were not propped open during this inspection and the home had been sourcing appropriate door safety devices. The proprietor informed the Inspector that they would also seek advise from the local Fire Safety Officer to ensure the safety devices were suitable for the home. The home held residents meetings and had given out questionnaires to residents and their relatives regarding the service offered. A copy of the feedback was given to the Inspector, very positive statements had been made about the home and the service provided. A copy of the feedback was also made available to the residents and their relatives. The Inspector recommended that a copy be placed in the service user guide in order to assist prospective residents and their families make a decision about moving to the home. The Inspector sampled a number of residents’ records regarding finance. The home keeps a monthly record of expenditure a copy of which is sent at the end of each month to specified relatives or representatives. Very little cash is kept and payments made by residents for additional services such as hairdressing and newspapers are paid for by cheque. The records are kept in order and where necessary archived by the home for future reference. Separate files for staff supervision and training including induction are kept by the home. Those sampled by the Inspector were up to date and on target. As this was an unannounced inspection and took place over five hours it was agreed that the home would forward detailed information confirming provision of their safety certificates to the CSCI. The certificates to include electrical safety, fire safety, PAT testing, COSHH (chemicals hazardous to health) and legionella testing and risk assessments regarding the building. Grace Lodge DS0000013654.V257329.R01.S.doc Version 5.0 Page 17 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X X X 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 3 3 3 3 X 2 Grace Lodge DS0000013654.V257329.R01.S.doc Version 5.0 Page 18 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 5 Regulation 4(1)(a)(b) (c) Requirement The registered person must review the statement of purpose with particular regard to the training of staff and the possible use of restraint. Timescale of 31st August 2005 not met. The registered person must forward information confirming the provision of the homes safety certificates to the CSCI. Timescale for action 30/11/05 2 38 23(2) 31/10/05 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 33 Good Practice Recommendations It is recommended that the home place the outcomes of their quality assurance process in the service user guide. Grace Lodge DS0000013654.V257329.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Grace Lodge DS0000013654.V257329.R01.S.doc Version 5.0 Page 20 - 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. 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