Inspection on 23/01/07 for Gresham Lodge

This inspection was carried out on 23rd January 2007.

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 02/03/06

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 Key Unannounced Inspection 23rd January 2007 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 Gresham Lodge DS0000061798.V328328.R01.S.doc Version 5.2 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.V328328.R01.S.doc Version 5.2 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 Position Vacant Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Gresham Lodge DS0000061798.V328328.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd March 2006 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. Information about the home and its service can be found in the statement of purpose and service user guide, both these documents are available from the manager of the home. A copy of the latest inspection report for the home is on display in the reception area of Gresham Lodge. Information given by the manager on 27/11/06 within the Pre-Inspection Questionnaire indicates the home charges a range of fees from £327.00 to £329.60 per week and that there are additional charges for hairdressing, private chiropody treatment, toiletries and newspapers/magazines. Information on the specific charges for these can be found in the Service User Guide. Gresham Lodge DS0000061798.V328328.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Since the last inspection in March 2006 the registered manager for Gresham lodge has left and a new person (Suzanne Treece) has been appointed to the post. Ms Treece has yet to be registered with the Commission but within this report she is referred to as the manager. This unannounced inspection was carried out with the manager, staff, relatives and residents of Gresham Lodge. The inspection took place over 1 day and included a tour of the premises, examination of staff and resident files and records relating to the service. Staffs on duty, four of the residents and two relatives were spoken to; their comments have been included in this report. Information was gathered from a number of different sources before the inspector visited the home. Questionnaires were sent out to a selection of relatives, residents and staff and their written response to these was adequate. The inspector received 9 back from relatives (45 ), 1 from staff (7 ) and 10 from residents (50 ). The provider completed a pre-inspection questionnaire and returned this to the Commission within the given timescale. What the service does well: The home has an experienced and enthusiastic team of staff who work well together and enjoy taking part in training and development sessions. The staff are motivated and keen to ensure that residents receive high standards of care. Residents have good access to professional medical staff and are able to access external services such as dentists and opticians. Meals are well presented and offer people at the home a choice and variety of different foods. Visitors to the home are made welcome and the home has a relaxed atmosphere that encourages families and friends to join in with activities and other social events. The home is welcoming and has a relaxed atmosphere. Residents said they are happy with their bedrooms and can bring in their own possessions, making it feel more like home. Gresham Lodge DS0000061798.V328328.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Gresham Lodge DS0000061798.V328328.R01.S.doc Version 5.2 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.V328328.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 6. Quality in this outcome area is good. 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. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The statement of purpose and service user guide is in the process of being up dated to reflect the changes in staff and management within the home. These documents are usually kept in the manager’s office and copies are available to interested parties on request. The inspector discussed the recent amendments to the Care Home regulations (September 2006) with the provider and manager, in particular the changes to regulation 5, which affects information within the service user guide. A copy of the last inspection report (March 2006) is on display in the entrance hall of the home, and information around advocacy and support groups is also available in this area for residents and relatives to read. Gresham Lodge DS0000061798.V328328.R01.S.doc Version 5.2 Page 9 Information from the surveys shows that the residents received sufficient information to make an informed choice about the service before accepting the placement offer. These individuals have also received a contract/statement of terms and conditions from the home. One individual said ‘ the brochure was informative and clearly written. A visit to the home confirmed the calm, clean and comfortable atmosphere of the service’. Each resident has their own individual file and four of those looked 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. The home develops a care plan from the assessments, identifying the individual’s problems, needs and abilities using the information gathered from the resident and family. Information from the Pre-Inspection Questionnaire completed by the manager and discussion with the residents, indicates that seventeen of the residents are female and three are male. Everyone is of a white/British nationality, but the home would assess any person with specific cultural or diverse needs on an individual basis. Discussion with the manager indicated that the home looks after a number of people from the local community, although placements are open to individuals from all areas. Residents are unable to make a choice of staff gender when deciding whom they would like to deliver their care, as the home has only female care staff. The manager said this was due to a lack of suitable male applications when jobs are advertised. The staff training files and the training matrix show that new staff go through an induction before starting work and that the home has a training programme in place. Information from the files and matrix indicates that the majority of staff are up to date with their basic mandatory safe working practice training, and the manager said she is looking into providing training in more specialised subjects linked to conditions of old age. The employment records show that the manager is using a selective approach to recruitment; ensuring new staff have the right skills and attitude to meet the needs of the residents. Comments from the relatives and residents surveys indicate they are pleased with the care being given and have a good relationship with the staff. The home does not accept intermediate care placements so standard six is not applicable to the service provided. Gresham Lodge DS0000061798.V328328.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. The health needs of the residents are being met, with evidence of good multi disciplinary working taking place on a regular basis. Improvements to the care planning system is needed, to ensure staff have well written and up to date records that reflect the care being given. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Individual care plans are in place for all residents and the four examined clearly set out the health, personal and social care needs identified for each person. The plans looked at have been evaluated on an irregular basis, but some changes to the care being given are documented and implemented by the staff. It was discussed with the manager that staff must review the plans on a monthly basis, and more often where residents are poorly or have a number of perceived risks such as nutrition and falls. Risk assessments were seen to cover pressure sores, mobility, nutrition, moving/handling and activities of daily living. Information about the resident’s social interests, likes and dislikes, spiritual needs and wishes regarding death Gresham Lodge DS0000061798.V328328.R01.S.doc Version 5.2 Page 11 and dying are all included within the individuals care plan. Individual choices and decisions about how care is to be given were also documented and residents said that staff respect their wishes. Areas where the plans could be improved include •Putting a photograph of the resident inside their file (positive identification). •Staff must ensure the residents full name is entered on each sheet within the care plan. •One plan seen at this visit had no risk assessment for bed rails. These must be completed for everyone using this type of equipment and be signed by the resident or his/her representative. •Staff are leaving gaps between the daily entries. These must be crossed through with one straight line and in future staff must start the next entry directly below the previous one. The funding authorities are carrying out yearly reviews of the care plans and the minutes of these meetings show that residents have input to this process (where possible), and family/representatives are also invited to the reviews with the resident’s permission. Two residents said that they have good access to their GP’s, chiropody, dentist and optician services, with records of their visits being written into their care plans. They all have access to outpatient appointments at the hospital and records show that they have an escort from the home if wished. Responses to the surveys indicated that the residents and relatives are satisfied with the level of medical support given to the people living at the home. One resident said ‘ the district nurse will come when required and the GP’s attend whenever I ask for a visit’. Comments from the residents and relatives indicate there is a high level of satisfaction about the care given at the home. One individual wrote ‘ I could not wish for better care and support. My comfort and wellbeing are always considered, and the staff are dedicated workers. After a recent illness the care staff have looked after me over and above the call of duty’. Relatives commented that they are kept informed of their relative’s wellbeing by the staff; they are regularly consulted (were appropriate) on their care and feel involved in their lives. A discussion took place between the inspector, provider and manager about recent Department of Health guidance around a possible Flu Pandemic in 2009. The need for an emergency plan for the home in the event of a Flu crisis was spoken about and the inspector advised that the provider access the guidance for care homes from the Department of Health website. All staff administering medication to residents at Gresham Lodge have undergone medication training and the home uses a Nomad Cassette system supplied by a local chemist. Gresham Lodge DS0000061798.V328328.R01.S.doc Version 5.2 Page 12 At the last visit (March 2006) a requirement was made for improvements to the handling and recording of the medication within the home. This has now been met. Checks of the medication records at this visit showed that staff are recording more consistently on the charts and there is only one area that could be improved as a matter of good practice. ∗Where staff are hand writing medication onto the sheets (transcribing), they should have two staff sign the entry to indicate they have both witnessed that the information on the sheet is correct. The recommendation from the last visit (March 2006) that the manager should conduct a weekly audit of the medication records has been actioned and clearly is having a good effect on staff practice. Checks of the controlled drugs and register showed that these are up to date, accurate and well managed. Resident and relative comments show they are very satisfied with the care and support offered by the staff. Chats with the residents revealed that they are happy with the way in which personal care is given at the home, and they feel that the staff respect their wishes and choices regarding privacy and dignity. Two individuals spoken to said ‘ the staff are lovely, they are always around to offer help and support when we need it and are very considerate of our feelings’. 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. I do go into the lounge when I want company and I can see my visitors in my own room where we have peace and quiet to talk in’. Gresham Lodge DS0000061798.V328328.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. Residents are provided with choice and diversity in the meals and activities provided by the home. Relatives and visitors are made welcome at the home and good links to the community enrich the residents social and leisure opportunities. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information from the resident surveys showed that everyone is satisfied with the social activities on offer and individuals felt there was always something they could participate in. In house entertainment is provided on a regular basis and trips out using a hired minibus are arranged for summertime. Since the last visit in March 2006 the provider recognised that there was a need for organised activities and the home has taken on an activities coordinator who spends 2 days (10 hours) a week organising and carrying out specific social events and entertainment. At the time of this visit this individual was on leave and the residents said that they missed her and looked forward to her return. Two residents said they enjoyed playing bingo and reading books from the mobile library, others were busy reading their newspapers and magazines. One person told the inspector Gresham Lodge DS0000061798.V328328.R01.S.doc Version 5.2 Page 14 that ‘ Activities are arranged for the residents, but being bedfast at the moment, and extremely deaf, I am unable to take part. Previously I have enjoyed craft activities although needing great help due to my age and infirmities. Visiting musicians come into my room and sing to me’. Residents’ files indicate that there are a number of individuals who follow different spiritual faiths, including Church of England, Methodist and Catholicism. Discussion with the residents showed that they do not want to go to church on a regular basis, but those expressing a wish to do so are assisted by the staff to attend local services. Major Christian festivals (Easter and Christmas) and birthdays are celebrated within the home and families are encouraged to join in with these events. Discussion with the residents indicates that they have good contact with their families and friends. Everyone said they were able to see visitors in the lounge or in their own room and they could go out of the home with family or staff would take them into the town. Visitors were seen coming and going during the day, staff were observed making them welcome and there clearly was a good relationship between all parties. Two relatives spoken to were full of praise for the staff and the home, one said ‘we are very pleased with the care that our mum receives, she is well looked after and if we have any problems we can talk to the staff or manager about them’. Information about advocacy services is on display in the home and includes leaflets made available to the residents and relatives. Two residents spoken to were well aware of their rights and said that they had family members who acted on their behalf and took care of their finances. Information from the pre-inspection questionnaire indicates one resident manages their own finances and all others have family or a representative overseeing their monies. Residents spoken to are satisfied that they can access their personal allowances when needed. Relatives and residents said that they attend regular meetings in the home, where they can voice their viewpoints and air their opinions on the home and service. These are listened to by the management team and acted on appropriately. All the residents said that the home encouraged them to bring in small items of furniture and personal possessions to decorate their bedrooms. Comments from the surveys received from staff, residents and relatives indicate that overall there is a good level of satisfaction with the meals provided by the home. The home has employed a new cook who has only been in post for one week; at the moment she is still getting to know the residents and their likes and dislikes. Observation of the midday meal showed it to be well prepared and presented, and the kitchen staff had made an effort to provide soft/pureed diets in an attractive way. Staff were organised when serving the meal and a number of Gresham Lodge DS0000061798.V328328.R01.S.doc Version 5.2 Page 15 individuals were seen to offer assistance to residents who need help with eating and drinking. Menus are available on the dining tables and jugs of squash were seen in the dining room and lounges. One resident said’ I would like to commend the staff for their help in feeding me and ensuring the food is suitably prepared, as I find it difficult to feed myself’. Gresham Lodge DS0000061798.V328328.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. The home has a satisfactory complaints system with some evidence that residents feel that their views are listened to and acted upon. Staff and residents are confident about reporting any concerns and the manager acts quickly on any issues raised. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents spoken to said that they had no complaints about the home and felt confident to raise issues of concern if they arose. Individuals said they could express their opinions in the satisfaction surveys they complete each year and that the manager is always available for them to talk to if needed. One resident said ‘ I have not needed to use the complaints process and my family and I are delighted with the care’. Information from the pre-inspection questionnaire and checks of the complaints records indicates that the home has not had any formal complaints since the last inspection. Information from the Pre-Inspection Questionnaire and discussion with the manager indicates that 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.V328328.R01.S.doc Version 5.2 Page 17 Three residents spoken to said they felt safe within the home and staff looked after their welfare. Discussion with the manager indicated that staff receive training around adult protection issues through their induction programme and National Vocational Qualification training. The manager has also arranged for individuals to attend adult protection training from the local Protection of Vulnerable Adults team (North Lincolnshire Council). Gresham Lodge DS0000061798.V328328.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 22, 24 and 26. Quality in this outcome area is adequate. The provider and manager have a good understanding of the areas in which the home needs to improve. Planning is in place and sets out how this improvement is going to be resourced and managed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has an ongoing programme of routine maintenance and decoration that ensures the environment is kept safe and well presented. Discussion with the provider indicated that he is waiting for council feedback on plans to alter the facilities at the home. He has delayed implementing the requirements and recommendations for standards 21 and 24 (from the March 2006 report) until he knows what the outcomes of his plans are. This should be known by April 2007. Observation of the premises showed that all areas seen were clean and tidy with no malodours present. Gresham Lodge DS0000061798.V328328.R01.S.doc Version 5.2 Page 19 No action has been taken regarding the bathroom that was used as a storeroom in November 2005 and subsequently cleared of all waste items (March 2006). The Fire officer’s report for the building, carried out in December 2006 mentioned an inappropriately stored mattress and the manager said this too has been removed. The recommendation made in the March 2006 report for ‘the provider to consider how the bathroom used as a storeroom could be adapted to provide residents with a suitable bathing facility’ will remain in this report. Gresham lodge is a large house set back from a busy road in Scunthorpe, there is car parking to the front of the house and a large garden to the rear of the home, provided with flat walkways for residents to mobilise on and seating areas available at the side of the building. Inside the home there are a number of double and single rooms on two floors providing bedroom accommodation for the residents. Access to the upper floor is by use of stairs or a stair lift. The recent fire officer’s report (December 2006) states that the home must complete a fire risk assessment for the stair lift, as the current assessment does not meet with current fire legislation and regulations. The provider said that he will take action within the given timescales of the fire officer’s report. Discussion with the manager indicated that she is going to risk assess all residents to ensure the more mobile individuals are placed on the first floor and those with mobility problems are given ground floor accommodation. The stair lift in use at the time of this visit is well maintained and does not present a risk to the residents. The home has corridors wide enough for a wheelchair or person using a Zimmer frame to pass along comfortably and thought has gone into providing flat walkways for those with difficulty mobilising. Doorways into communal areas, bedrooms and bathrooms are wide enough for equipment to fit through, and assisted bathing facilities are in place. Discussion with the staff indicates that there is a good range of equipment to help with the moving and handling of the residents and to encourage their independence; this includes hoists and handrails. The provision of bedroom door locks, lockable drawer facilities and keys are outstanding requirements from previous inspections. Given timescales of 31/07/05 and 01/06/06 were not met, and the requirements will remain on this report. Information in some of the care plans seen during this visit suggests that residents have been asked if they wanted a door lock fitting or not. 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 provider should supply as standard, lockable facilities and privacy locks to bedroom doors when current occupants vacate the bedrooms. Gresham Lodge DS0000061798.V328328.R01.S.doc Version 5.2 Page 20 The laundry within the home is situated in a small room and this does not have the space to provide separate clean and dirty laundry areas, although clean clothes are put into baskets on wall shelves. The home’s sluice machine for commodes is also found in this area. The inspector is satisfied that at the time of this visit staff showed good knowledge around infection control and their practices are appropriate. The manager should ensure there are clear infection control policies for use of the sluice in the laundry area and the separation of clean and dirty laundry. The provider should ensure that future plans for the home include a more suitable laundry facility that promotes good hygiene practices and controls the spread of infection, and a separate commode sluicing facility. Comments from the surveys indicates that the residents find the home to be spotlessly clean and are satisfied with the laundry service provided by the home. Gresham Lodge DS0000061798.V328328.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. Staff morale is high resulting in an enthusiastic workforce that works positively with residents to improve their whole quality of life. Improvements are needed to the recruitment practices to ensure the standard of vetting and obtaining appropriate references remains high, protecting residents from risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Comments received from the residents, relatives and staff were positive about the staffing levels, and everyone was satisfied that there were sufficient people on duty to meet the needs of the residents. One resident said that ‘being bedfast at the moment, the staff are always looking in to check on me and to ensure that I am comfortable’. Staff morale on the whole is good, and individuals said that there is a good working atmosphere at the home. Inspection of the duty rota and discussion with the manager indicates that the staffing levels at the home remain the same as at the last inspection. 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. The manager’s hours are supernumerary to these and she works 9am-5pm Monday to Friday. Gresham Lodge DS0000061798.V328328.R01.S.doc Version 5.2 Page 22 Information from the pre-inspection questionnaire and staff rotas about the number of staffing hours provided and the dependency levels of the residents, was used with the Residential Staffing Forum Guidance and showed that the home is meeting the recommended guidelines. There is an induction and foundation course for new members of staff, and 42 of the care staff have achieved an NVQ 2 or 3. The home provides a mandatory staff-training programme and the manager plans to add more specialised training that reflects the different care needs of the client group. There is no evidence that staff have received training around equality, diversity and disability rights and this should be included in the rolling programme of staff training and development. The home has an equal opportunities policy and procedure. Information from the staff personnel and training records and discussion with the manager, shows that that this is promoted when employing new staff and throughout the working practices of the home. The manager said that the home has tried to recruit male carers in the past as she is aware that all of the staff are female, but this has proved difficult as there have been few suitable applicants. She is aware that this may affect resident’s wishes regarding gender choice for giving of personal care, and this is discussed before an individual is offered a placement at the home. Comments from the manager indicate that all of the residents are from a white British background, but the home is able to offer a range of services when they are approached from someone of another culture or ethnic group. The home has a recruitment policy and procedure that the manager understands and this has been followed in the past. However on checking four staff files it was found that two new starters have been employed before their references were obtained. This was discussed with the manager and she assured the inspector that the references would be ‘followed up’ immediately, and in future no one would start work without their references being in place. The inspector is satisfied that this is not the usual way of working within the home and will monitor this at the next visit. The home has been using the process of obtaining the Protection of Vulnerable Adults first check for all new starters before receiving the Criminal Records Bureau check. It was discussed with the manager that this was only to be done in extreme circumstances where the home was desperately short of staff, and should not become a regular part of the employment process. Gresham Lodge DS0000061798.V328328.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. The management of the home is satisfactory overall and the home regularly reviews aspects of its performance through a good programme of audits and consultations, which includes seeking the views of residents, staff and relatives. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last visit (March 2006) the registered manager has moved to another home within the company and Suzanne Treece has been appointed in this post. Suzanne is not registered with the Commission although her manager application is being processed, and she is enrolling on the Registered Managers Award training and hopes to have achieved this by the end of 2007. Gresham Lodge DS0000061798.V328328.R01.S.doc Version 5.2 Page 24 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. The home is also accredited with Investor in People Status, and this too has been reaffirmed. Feedback is sought from the residents and relatives through regular meetings and satisfaction questionnaires. There is an Annual Development Plan in place and the manager is gathering information for the production of this years report. Policies and procedures are up dated and reviewed as an ongoing practice and action is being taken to ensure the requirements of the inspection reports are met. 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. 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’. Maintenance certificates are in place and up to date for all the utilities and equipment within the building. Accident books are filled in appropriately, but the completed forms need to be filed away either in the manager’s office or in the residents care plans. The inspector recommended that the manager complete a monthly audit on these to help spot any problems or recurring themes. The inspector discussed with the manager the circumstances in which the home must report incidents to the Commission, using the Regulation 37 report forms. The Fire Officer’s report for December 2006 said that the home must up date its fire risk assessment. Discussion with the provider and manager indicated that this was being done and would be completed within the given timescales of the Fire Officer’s report. Staff have received training in safe working practices and the manager has completed generic risk assessments for a safe environment within the home. Gresham Lodge DS0000061798.V328328.R01.S.doc Version 5.2 Page 25 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 3 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 3 2 X 3 2 X 2 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Gresham Lodge DS0000061798.V328328.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement The manager must ensure that the residents care plans are reviewed by care staff at least once a month, updated to reflect changing needs and current objectives for health and personal care, and actioned. Risk assessments must be completed where bed rails are in use and agreed with the resident or their representative. The provider must ensure the building complies with the requirements of the Fire Officer’s report. The provider must ensure that the fire risk assessment for the stair lift meets the requirements of the Fire Service. Door locks must be fitted to all bedrooms, unless the resident specifically requests that this is not done. This information must be documented. Given timescales of 31/07/05 and 01/06/06 were not met. Residents must be provided with keys unless their risk DS0000061798.V328328.R01.S.doc Timescale for action 01/06/07 2. OP19 24 01/04/07 3. OP22 16, 23 01/04/07 4. OP24 12 01/06/07 5. OP24 12 01/06/07 Gresham Lodge Version 5.2 Page 27 6. OP24 12 assessment suggests otherwise. Given timescale of 01/06/06 was not met. 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). Given timescale of 01/06/06 was not met. The manager must ensure that two written references are obtained before appointing a member of staff. A manager must be appointed and registered with the Commission. 01/06/07 7. OP29 19 01/06/07 8. OP31 8 01/06/07 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 OP7 OP8 OP9 Good Practice Recommendations The manager should ensure care plans include positive identification of the residents and staff complete daily records without leaving gaps between the entries. The provider should ensure the home has an emergency crisis plan for the possible Flu Pandemic by the end of 2007. Where staff are hand writing medication onto the sheets (transcribing), they should have two staff sign the entry to indicate they have both witnessed that the information on the sheet is correct. The provider should consider how the bathroom used as a storeroom could be adapted to provide residents with a suitable bathing facility. The provider should supply as standard, lockable facilities and privacy locks to bedroom doors when current DS0000061798.V328328.R01.S.doc Version 5.2 Page 28 4. OP21 5. OP24 Gresham Lodge 6. 7. OP26 OP26 8. 9. 10. 11. 12. OP28 OP30 OP31 OP38 OP38 occupants vacate the bedrooms. The manager should ensure there are clear infection control policies for use of the sluice in the laundry area and the separation of clean and dirty laundry. The provider should ensure that future plans for the home include a more suitable laundry facility that promotes good hygiene practices and controls the spread of infection, and a separate commode sluicing facility. 50 of the care staff should have achieved an NVQ 2 by the end of 2007. Staff should receive training around equality, diversity and disability rights and this should be included in the rolling programme of staff training and development. The registered manager should achieve an NVQ 4 in management and care by the end of 2007. The manager should ensure that completed accident forms are filed away appropriately, and an audit carried out monthly to spot any trends or patterns in the accidents. The manager should complete the fire risk assessment update within the given timescales of the fire officer’s report. Gresham Lodge DS0000061798.V328328.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Hessle Area Office First Floor 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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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