Inspection on 17/11/05 for Gresham Lodge

This inspection was carried out on 17th November 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

Gresham Lodge 13/11/07

Gresham Lodge 23/01/07

Gresham Lodge 02/03/06

Gresham Lodge 03/03/05

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

CARE HOMES FOR OLDER PEOPLE Gresham Lodge Gresham Lodge 255 Ashby Road Scunthorpe North Lincs DN16 2AB Lead Inspector Eileen Engelmann Unannounced Inspection 17th November 2005 09:30 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 Gresham Lodge DS0000061798.V263469.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. Gresham Lodge DS0000061798.V263469.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Gresham Lodge Address Gresham Lodge 255 Ashby Road Scunthorpe North Lincs DN16 2AB 01724 846504 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 Sukhuinder Marjara Angela Smith Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Gresham Lodge DS0000061798.V263469.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd March 2005 Brief Description of the Service: Gresham Lodge is a well established home situated in a pleasant central location of Scunthorpe, it has access to local amenities and public transport. The home is registered to provide care for up to twenty-one service users with problems associated with old age. The home consists of two storeys accessed by stairs and a stair lift. There are thirteen single and four double rooms; none of these are en-suite. Communal areas are provided for residents to spend time in with others, and these include a conservatory and open plan sitting and dining areas. The home has pleasant rear gardens with ample parking to the front of the property. Gresham Lodge DS0000061798.V263469.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out with the Registered Provider, the manager, staff and residents of Gresham Lodge. The inspection took 6 hours and included a tour of the premises, examination of staff and resident files and records relating to the service. Five of the residents were spoken to in an informal manner; their comments have been included in this report. What the service does well: What has improved since the last inspection? Staff have worked hard to create detailed and informative care records that reflect the care being given, the progress made by the individual residents, and which clearly show the residents choices, preferences and decisions about their daily lives. Residents are pleased with the way care is being given and said ‘the staff are very supportive and encourage everyone to be as independent as possible’. The home cares for older people with special needs, and staff have extra training to help them do this well. Gresham Lodge DS0000061798.V263469.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. Gresham Lodge DS0000061798.V263469.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 Gresham Lodge DS0000061798.V263469.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): 3. Standard 6 is not applicable to this service. Progress has been made to develop the homes needs assessment to ensure that it covers all aspects of care. All residents undergo a full needs assessment and are given sufficient information about the home and its facilities prior to admission, to enable them to be confident that their needs can be met by the service. EVIDENCE: Since the last inspection the manager has up dated the homes needs assessment for self-funding individuals and the paperwork now meets the criteria for Standard 3 (National Standards and Regulations for Care Homes for Older People 2003). Each resident has their own individual file and all three of those looked at had a full needs assessment completed within them, including one for a privately paying individual. The information from the assessment process is used to formulate the individuals care plan. The manager said that she verbally tells individuals if the home can meet their needs, and this process would be developed into a written format. Gresham Lodge DS0000061798.V263469.R01.S.doc Version 5.0 Page 9 Two residents spoken to were able to give detailed information about their care needs and the input they required from the staff, service and outside professionals, and this was found to be accurately documented within their care plans. Gresham Lodge DS0000061798.V263469.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 and 10. The health, personal and social care needs of the residents are clearly documented and are being met by the service and staff. Residents are encouraged to be independent within their daily lives using a risk assessment approach to care. EVIDENCE: Individual care plans are in place for all residents and clearly set out the health, personal and social care needs identified for each person. Three of the plans looked at have been evaluated on a monthly basis and any changes to the care being given is documented and implemented by the staff. One resident said that she likes to be as independent as possible and demonstrated a good understanding of her abilities and needs regarding care. Her wishes and choices are clearly recorded in her care plan, as are her expectations around how her care is to be given. Risks assessments are also in place. Three residents said that they have good access to their GP’s, chiropody, dentist and opticians. They all attend outpatient appointments at the hospital and records show that they have an escort from the home if wished. The Gresham Lodge DS0000061798.V263469.R01.S.doc Version 5.0 Page 11 District Nurse provides nursing care at the home, and where applicable her visits are recorded in the individual’s care plan. The medication policy for the home says that individuals can self-medicate if they want to and after a risk assessment has been completed and agreed. All five of the residents spoken to prefer to have staff administer their medication and are satisfied with the way this is carried out. Checks of the medication records and the system used showed that these are up to date, accurate and well managed. Staff records show that they have all received medication training and understand the system. The five residents spoken to were very pleased with the way that care is given by the staff. Two individuals said that ‘ staff are kind and caring, they are supportive and give us choice in all our daily actions’. Staff and residents were communicating in a friendly and relaxed manner with jokes and light-hearted banter being shared with everyone. One resident said that ‘the staff respect my privacy and understand that I like to spend time alone in my room, they come and check on me but realise that I prefer my own company’. Gresham Lodge DS0000061798.V263469.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Residents are provided with choice and diversity in the meals and activities provided by the home. Individual wishes and needs are catered for and people have the option of where, when and how they participate in both eating and leisure activities. EVIDENCE: The home has a weekly programme of social activities for the residents that are carried out by the care assistants. In house entertainment is provided on a regular basis and trips out using a hired minibus are arranged for summertime. One resident was celebrating her 101st Birthday during this visit and staff and family had sent cards/presents. This lady was looking forward to the buffet tea that the home was providing for her special day and was surrounded by well wishers and friends within the home. All those who spoke to the inspector were satisfied with the activities and entertainment provided by the home, and looked forward to the events planned for Christmas. One individual clearly stated that she did not want to join in with any social activities; she said that she enjoyed watching television and had a television guide and newspaper delivered daily. Visitors were seen coming and going within the home throughout the day. There is an open visiting policy in place and the residents spoken to are pleased with the arrangements saying ‘our families and friends come to see us Gresham Lodge DS0000061798.V263469.R01.S.doc Version 5.0 Page 13 on a regular basis and we can go out with them at any time’. Residents are able to go out into the local community to the shops and pubs with the staff or visitors, one individual visits The Blind Society and there is a church service in the home every three weeks. Discussion with five residents showed that they are offered choice in their daily activities and have a good awareness of their rights. Advocacy information is available throughout the home and one individual spoken to said she is able to manage her own finances with some support from her legal advisor. The residents said that they have a meeting every month and can voice their opinions and views of the service at this time. They were happy that the manager acted on any issues that needed resolving and they received feedback at the next meeting as to what action had been taken. All residents spoken to were full of praise for the quality and quantity of the meals provided at the home. Two individuals commented that ‘the cooks are excellent at their job, we are offered different choices of meals every day and can take our meals where we want’. One resident said she enjoys breakfast in her room and joins the other residents for lunch and tea in the dining room. Gresham Lodge DS0000061798.V263469.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): Arrangements for protecting residents are not satisfactory, placing them at possible risk of harm or abuse. EVIDENCE: The home has a clear and simple complaints procedure that residents and staff are aware of and are confident of using if needed. The complaints records show that there have been no complaints made since the last inspection and residents spoken to said ‘Angela (the manager) comes round to see us every day and talks to us about any niggles we may have. She tries to solve them immediately and will get back to us if she needs to take time to resolve them’. The home has policies and procedures to cover adult protection and prevention of abuse, whistle blowing, aggression, physical intervention and restraint and management of resident’s money and financial affairs. Information in the staff files indicated that they had received training around abuse and vulnerable adults during their Induction process and NVQ training. The home has a copy of the ‘No Secrets’ documentation and the manager displayed a good understanding of the process for reporting any concerns to the Protection of Vulnerable Adult (POVA) team. Examination of a number of staff files showed that although the majority of staff have CRB checks in place, some of the new staff were started in employment before the results of their POVA First checks were obtained. There is no evidence that these individuals were supervised during their work Gresham Lodge DS0000061798.V263469.R01.S.doc Version 5.0 Page 15 and this leaves the residents at risk of harm and is not acceptable practice. The provider and manager assured the inspector that from now on new staff would not start work until the checks are completed. This will be followed up at the next inspection and monitored at future visits. Gresham Lodge DS0000061798.V263469.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, 21, 24 and 26. Residents are provided with a safe, comfortable and clean environment. They are able to personalise their own rooms, however their belongings cannot be kept safe as no progress has been made on the provision of door locks. EVIDENCE: The home has had a number of bedrooms and communal areas redecorated since the last inspection, and all areas seen were bright, clean and odour free. One bathroom is being used as a storeroom and this is not acceptable practice, as the area does not have a smoke detector in place. The manager was asked to remove the items from the room or ensure it met fire regulations. It is important that residents have access to a range of bathing facilities and if the bathroom is out of commission because it is not suitable for use by the residents, then thought should be given to adapting it to provide a facility that can meet their needs. Residents have access to a large garden to the rear of the home, this is provided with flat walkways for them to mobilise on and seating areas are available at the side of the building. Gresham Lodge DS0000061798.V263469.R01.S.doc Version 5.0 Page 17 Five residents spoken to were very pleased with their individual rooms and said that they had ‘brought in a number of personal possessions to make them feel more homely’. The provision of bedroom door locks and keys remain outstanding requirements from the previous inspections. The Provider said that he would fit a door lock for any resident who requested this and plans to fit locks throughout the home as part of the future development of the environment. Lockable drawer facilities in each room are also part of the ongoing refurbishment of the home, and will be provided as the bedroom furniture is replaced. The home is clean, warm and comfortable and no malodours were present. Domestic staff spoken to said that they ‘follow a deep cleaning rota to ensure that all bedrooms are thoroughly cleaned from top to bottom on a regular basis’. Gresham Lodge DS0000061798.V263469.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 and 30. The standard of vetting and recruitment practices is not satisfactory and potentially leaves residents at risk of harm. Staffing numbers are sufficient to meet the needs of the residents and carry out activities. EVIDENCE: Information in the staffing rotas shows that there is three care staff on duty during the day shift and two care staff at night. Each shift has a senior staff member on duty to organise the work routine, and additional ancillary staff are on duty throughout the day. Residents spoken to are very happy with the amount of staff on duty and said ‘they are always helpful and available to see to anything you need doing and nothing is too much bother’. The home has policies in place for recruitment and selection, equal opportunities, staff grievance, disciplinary, and working with volunteers. Checks of three staff files showed that these have been brought up to date since the last inspection with two written references, health declarations, job descriptions and past working history all being obtained and discussed before employment. The majority of the staff have a CRB report within their files, but two of the three staff files looked at showed the employees had started work before their POVA First check had been obtained by the home. Anyone working at the home who has had a POVA First completed and before their CRB report is received by the Provider, must be supervised at all times. There was no evidence in the staff files to indicate that these individuals had received Gresham Lodge DS0000061798.V263469.R01.S.doc Version 5.0 Page 19 supervision during their work hours. These are not acceptable practices and must stop immediately as it potentially puts the residents at risk of harm. The provider and manager assured the inspector that all future employees would not start work until the checks were completed and received. This area of practice will be checked at the next inspection and monitored on future visits. The staff-training programme offers staff access to mandatory training and some specialist subjects linked to the needs of the residents. There is an induction and foundation course that meets National Training Organisation (NTO) specification for new members of staff, and 20 of the care staff have achieved an NVQ 2 or 3, with one more staff member going through the training. Gresham Lodge DS0000061798.V263469.R01.S.doc Version 5.0 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33 and 38. The management of the home is satisfactory overall, with safe working practices being carried out within the home to protect the residents’ health, safety and wellbeing. EVIDENCE: Since the last inspection Angela Smith has been successful in registering with the Commission as the manager of Gresham Lodge. She is in the process of completing her Registered Managers Award and hopes to finish this within the next twelve months. Certificates on the wall of the home and discussion with the Provider and Manager indicate that the North Lincolnshire Council has awarded the home its Gold Standard for Quality Assurance, this award was achieved in 2004 and has been reaffirmed by the council since this time. Feedback is sought from the residents and relatives through regular meetings and satisfaction questionnaires. Policies and procedures are up dated and reviewed as an Gresham Lodge DS0000061798.V263469.R01.S.doc Version 5.0 Page 21 ongoing practice and action is being taken to ensure the requirements of the inspection reports are met. Maintenance certificates are in place and up to date for all the utilities and equipment within the building. The Provider is waiting for the electrical wiring certificate as this work was completed the week prior to the inspection; he is to send a copy of this to the Commission when it is received at the home. The manager has completed generic risk assessments for the premises and a fire risk assessment has been completed and reviewed. Staff are undergoing training in all safe working practices and accident books are filled in appropriately. Gresham Lodge DS0000061798.V263469.R01.S.doc Version 5.0 Page 22 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 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X 2 X X 2 X 3 STAFFING Standard No Score 27 3 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X X X X 3 Gresham Lodge DS0000061798.V263469.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? Yes. Gresham Lodge DS0000061798.V263469.R01.S.doc Version 5.0 Page 24 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 OP18 Regulation 12 Requirement The recruitment policy must be followed and all new staff must have a POVA First and/or a CRB check completed before they start work. The home must provide sufficient assisted bathing facilities to meet the needs of the residents. Door locks must be fitted to all bedrooms, unless the resident specifically requests that this is not done. This information must be documented. Given timescale of 31/07/05 was not met. Residents must be provided with keys unless their risk assessment suggests otherwise. Each resident must be provided with lockable storage space for medication, money and valuables and is provided with the key, which he or she can retain (unless the reason for not doing so is explained in the care plan). New staff must only be confirmed in post following completion of a satisfactory CRB check and a satisfactory check of the Protection of Vulnerable Adults register. Timescale for action 01/01/06 2 OP21 23 13/02/06 3 OP24 12 01/06/06 4 5 OP24 OP24 12 12 01/06/06 01/06/06 6 OP29 19 01/01/06 Gresham Lodge DS0000061798.V263469.R01.S.doc Version 5.0 Page 25 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 2 3 Refer to Standard OP21 OP28 OP31 Good Practice Recommendations The provider should consider how the bathroom used as a storeroom could be adapted to provide residents with a suitable bathing facility. 50 of the care staff should have achieved an NVQ 2 by 2005. The registered manager should achieve an NVQ 4 in management and care by 2005. Gresham Lodge DS0000061798.V263469.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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. 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