Inspection on 02/03/06 for Gresham Lodge

This inspection was carried out on 2nd March 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

Gresham Lodge 13/11/07

Gresham Lodge 23/01/07

Gresham Lodge 17/11/05

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 2nd March 2006 10:30 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.V264124.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. Gresham Lodge DS0000061798.V264124.R01.S.doc Version 5.1 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.V264124.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th November 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 residents 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.V264124.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out with the manager; staff and residents of Gresham Lodge care home. The inspection took 2.5 hours and included a tour of the premises, examination of staff and resident files and records relating to the service. Some of the residents were spoken with, as well as chats with staff members as they worked. All the key standards have been inspected in the past year and information on these and their outcomes can be found in the report for 17th November 2005 and this one. What the service does well: What has improved since the last inspection? What they could do better: Medication recording needs to be improved to ensure all signatures are in place for medications received and given out by the staff, so that there is no mishandling of medication and the residents health is looked after. Gresham Lodge DS0000061798.V264124.R01.S.doc Version 5.1 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. Gresham Lodge DS0000061798.V264124.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 Gresham Lodge DS0000061798.V264124.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): 3. The systems for pre-admission and assessment of resident needs are satisfactory and provide individuals with sufficient information to make an informed decision about their care. EVIDENCE: The home continues to meet the criteria of standard 3. All residents at the home have their own personal file and one of the three looked at was for a fairly new resident. Each individual had a need assessment completed by the funding authority and the home has also completed its own needs assessment before a placement was offered to the resident. 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.V264124.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 and 9. The systems for the administration and recording of medication are poor and potentially place residents at risk. EVIDENCE: The home continues to produce and keep clear and accurate care plans for the residents. Individual care plans are in place for all residents and set out the health, personal and social care needs identified for each person. Risk assessments are carried out for all individuals and three of the plans looked at have been evaluated on a monthly basis. Any changes to the care being given is documented and implemented by the staff. The one individual has sight and hearing impediments and his/her family have given detailed communication information to the staff, which has been documented into their care plan. This includes a communication routine for staff to follow. Gresham Lodge DS0000061798.V264124.R01.S.doc Version 5.1 Page 10 The standards of medication practices within the home are not as good as they were at the last inspection. Staff need to ensure they follow the homes policies and procedures when completing the paperwork. Examination of the medication records showed up a number of areas that need to improve. These include ∗There were a number of missing signatures from the staff who had given out medication to residents, but not recorded this fact. ∗Staff are not signing medication received from the pharmacy into the system. ∗Transcribed (handwritten onto the sheet) medication did not have the quantities received written down or two signatures from the staff to indicate that they had both checked the information recorded initially was correct. The above practices could lead to medication errors being made and are not acceptable to the Commission. The inspector recommended that an audit of the medication system should be carried out weekly to ensure the records are kept up to date and staff are using the system correctly. Gresham Lodge DS0000061798.V264124.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): 15. The meals in this home are good offering both choice and variety and catering for special dietary needs. EVIDENCE: Food at the home is well presented at meal times and comments from the residents indicated that they are pleased and satisfied with the quality and quantity of the meals. Observation of the midday meal showed that residents were enjoying the food and two individuals said ‘this is delicious’. The kitchen prepares appropriate meals for residents who are diabetic or who need a soft/pureed diet, taking care to present all the meals in an attractive way. Residents are able to take meals in their own rooms or in the dining room and those spoken to said that the staff always ask them for their choices of menu on a daily basis, and give them different options to choose from. Gresham Lodge DS0000061798.V264124.R01.S.doc Version 5.1 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): 16 and 18. The home has a satisfactory complaints system with some evidence that residents feel that their views are listened to and acted upon. Adult protection procedures have improved since the last inspection with clear evidence that residents are being protected from 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. Two residents showed a clear understanding about how to make their views and opinions heard and said ‘the manager comes round to see us regularly 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 complaints records show that the manager has received one informal complaint since the last inspection, and this has been investigated and resolved. In addition to this the Environmental Health Department came out to investigate a complaint it received, investigation by the EH officer showed the complaint was not valid and no further action was necessary. 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. Gresham Lodge DS0000061798.V264124.R01.S.doc Version 5.1 Page 13 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. Changes have been made to the recruitment practices since the last inspection. Examination of the staff files and discussion with the provider and manager indicates that the home is now making sure that all staff have a POVA first check completed and returned before they start employment. Senior staff supervise these individuals at work until a satisfactory CRB check is received by the home. Gresham Lodge DS0000061798.V264124.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, 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 an ongoing programme of routine maintenance and decoration that ensures the environment is kept safe and well presented. All areas seen by the inspector were clean, bright and well decorated, no malodours were noted. The bathroom used as a ‘store’ room at the time of the last inspection has been cleared of all waste items and thought is being given to its future use. 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 Gresham Lodge DS0000061798.V264124.R01.S.doc Version 5.1 Page 15 refurbishment of the home, and will be provided as the bedroom furniture is replaced. Gresham Lodge DS0000061798.V264124.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28 and 29. Since the last inspection the standard of staff recruitment has improved with appropriate checks being carried out and new staff being supervised, ensuring that residents are protected from risk of harm. EVIDENCE: 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 15 of the care staff have achieved an NVQ 2 or 3, with two more staff due to complete the training in March 2006 and three others (under 25’s) registered to go through the training. The manager said that she hopes to have 50 of staff with the qualification by the end of 2006. Checks of the staff files for new employees showed that the home has improved its recruitment practices since the last inspection. The manager ensures the necessary POVA First/CRB checks, written references, health checks and past work history are all obtained and are satisfactory before the person starts work. New employees, with a completed POVA First, are supervised by senior staff until their CRB check is back and found to be acceptable. Gresham Lodge DS0000061798.V264124.R01.S.doc Version 5.1 Page 17 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): Satisfactory accounting and financial systems are in place to protect and safeguard the interests of the residents. EVIDENCE: The manager for the home is registered with the Commission and is working towards achieving her Registered Managers Award by the end of June 2006. Checks of the financial records showed that residents are able to have Personal Allowance accounts in the home. These records are hand written and each person has their own account sheet, which is updated each week by the manager/administrator. Information from the manager indicates that the residents have a family member or representative who looks after their monies and these individuals make sure the Personal Allowances are sent/brought into the home. Gresham Lodge DS0000061798.V264124.R01.S.doc Version 5.1 Page 18 Each resident has their own wallet for their money and receipts of all transactions undertaken are kept in their file. Checks of these showed them to be accurate and up to date. The home does not keep large amounts of cash on the premises and if a person’s allowance builds up it is returned to the family/representative for ‘safe-keeping’. Gresham Lodge DS0000061798.V264124.R01.S.doc Version 5.1 Page 19 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 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 X X 2 X 3 STAFFING Standard No Score 27 X 28 2 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X 3 X X X Gresham Lodge DS0000061798.V264124.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? Yes. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13 Requirement Medicines in the custody of the home must be handled in accordance to the requirements of the Medicines Act 1968, guidelines from the Royal Pharmaceutical Society, the requirements of the Misuse of Drugs Act 1971. 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). Timescale for action 01/06/06 2. OP24 12 01/06/06 3. 4. OP24 OP24 12 12 01/06/06 01/06/06 Gresham Lodge DS0000061798.V264124.R01.S.doc Version 5.1 Page 21 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. 4. Refer to Standard OP9 OP21 OP28 OP31 Good Practice Recommendations The manager should carry out an audit of the medication system each week, to ensure the records are kept up to date and staff are using the system correctly. 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 the end of 2006. The registered manager should achieve an NVQ 4 in management and care by June 2006. Gresham Lodge DS0000061798.V264124.R01.S.doc Version 5.1 Page 22 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. Extracts may not be used or reproduced without the express permission of CSCI Gresham Lodge DS0000061798.V264124.R01.S.doc Version 5.1 Page 23 - 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!