Inspection on 09/08/06 for Pine Tree Care Home

This inspection was carried out on 9th August 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Pine Tree Care Home 14/04/10

Pine Tree Care Home 09/06/09

Pine Tree Care Home 16/07/08

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

CARE HOMES FOR OLDER PEOPLE Gwendolen Lodge Residential Home 305 Gwendolen Road Leicester Leicestershire LE5 5FP Lead Inspector Martin Hefferman Unannounced Inspection 9th August 2006 9:05 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 Gwendolen Lodge Residential Home DS0000066523.V305995.R02.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. Gwendolen Lodge Residential Home DS0000066523.V305995.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Gwendolen Lodge Residential Home Address 305 Gwendolen Road Leicester Leicestershire LE5 5FP 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) 0116 2738381 0116 2738381 Sudera Care Associates Limited Miss Janet Tailor Care Home 23 Category(ies) of Dementia (23), Dementia - over 65 years of age registration, with number (23), Mental disorder, excluding learning of places disability or dementia (23), Mental Disorder, excluding learning disability or dementia - over 65 years of age (23), Old age, not falling within any other category (23), Physical disability (23), Physical disability over 65 years of age (23) Gwendolen Lodge Residential Home DS0000066523.V305995.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. No person under the age of 55 who falls within categories MD, DE or PD may be admitted into the home. To be able to admit the named person of Category A(E) identified in variation application number V17739 dated 17th February 2005. 29/11/05 Date of last inspection Brief Description of the Service: Gwendolen Lodge Residential Home is registered to provide care for up to 23 older people. The home is located near to the centre of Leicester and is accessible by bus. Residents’ rooms are situated on both the ground and first floors. There are two dining areas and four lounges, one of which is a designated smoking area. All parts of the home are accessible for people with a disability. To the rear of the premises is a large garden / patio area. Fencing has been fitted to provide a safe and secure environment. At the time of the inspection, fees ranged from £380 to £390. Information for prospective residents is available. This is the first inspection completed since new owners took over the running of the home. Gwendolen Lodge Residential Home DS0000066523.V305995.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A visit to the home took place on 9th August 2006, lasting approximately six hours. The main method of inspection used on that day was ‘case tracking’ which involved selecting three residents and tracking the care they receive through review of their records, discussion with them, care staff and observation of care practices. Three residents were spoken to during the course of the inspection. The registered manager was present on the day of the visit. What the service does well: What has improved since the last inspection? What they could do better: Assessment practices should be reviewed to ensure that all needs are identified prior to a resident’s admission. The programme of activities should be reviewed to ensure that it meets residents’ expectations. Action should be taken to minimise the odour arising from the home’s cats. The registered provider should comply with the requirements of Regulation 26. The registered provider should seek to involve residents and their representatives in reviewing the quality of care provided at the home. Gwendolen Lodge Residential Home DS0000066523.V305995.R02.S.doc Version 5.2 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. Gwendolen Lodge Residential Home DS0000066523.V305995.R02.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 Gwendolen Lodge Residential Home DS0000066523.V305995.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Assessment practices could be strengthened further to ensure that all needs are identified prior to a resident’s admission. EVIDENCE: Completed assessments were available for two residents who had recently moved to the home. Both assessments set out brief details regarding each resident’s basic care needs. The registered manager stated that a document entitled ‘family tree’ would be used to obtain more background information about each person. The home had obtained a copy of a social worker’s assessment / care plan for one of the residents and a report completed by nursing staff for the second. The home does not provide intermediate care. Gwendolen Lodge Residential Home DS0000066523.V305995.R02.S.doc Version 5.2 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, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements for meeting residents’ health and personal care needs appear to be well managed. EVIDENCE: Individual plans were available for the residents who were chosen for the purposes of case tracking. Two of the plans - for residents who moved in during July and August 2006 – were brief, setting out basic information about the residents’ care needs. The third plan – for a resident who moved in during December 2005 – was very detailed, covering a wide range of health and social care needs. Records indicate that it had been kept under review. Individual plans contained details of any health care needs that had been identified and of any action that was felt to be necessary as a result. A record is kept of all appointments with health care professionals. Records of the medicines received into the home and administered to residents met relevant requirements. Senior members of care staff are responsible for the administration of medication. Records indicate that they have received relevant training. Gwendolen Lodge Residential Home DS0000066523.V305995.R02.S.doc Version 5.2 Page 10 Residents stated that staff members treat them with respect and that they are mindful of their right to privacy. They reported that staff members use their preferred form of address. Gwendolen Lodge Residential Home DS0000066523.V305995.R02.S.doc Version 5.2 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): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements relating to the daily life of residents appear to be generally well managed. The programme of activities should be reviewed to ensure that it meets residents’ expectations. EVIDENCE: On the day of the inspection, it was noted that one resident played dominoes with a member of staff, which she stated she enjoyed, and that a member of staff took a second resident outside to spend some time in the grounds. Other residents sat and watched television. A number of them received a local paper in the afternoon. One resident stated that he did not feel there was enough to do. The registered manager stated that she hopes to arrange some trips out, although this has proved difficult as the home no longer has access to a minibus. Regular religious services are held within the home. The registered manager agreed to talk to a resident who expressed an interest in attending a service. Records indicate that residents are able to maintain contact with their families and friends, where possible. This was confirmed by one of the residents who was chosen for the purposes of case tracking. Gwendolen Lodge Residential Home DS0000066523.V305995.R02.S.doc Version 5.2 Page 12 Residents stated that they are able to determine their own daily routine, deciding, for example, when to get up and to go to bed and how to spend their day. They reported that they are offered a choice of food and that they enjoy the meals that are provided. Records indicate that residents receive a varied diet. Gwendolen Lodge Residential Home DS0000066523.V305995.R02.S.doc Version 5.2 Page 13 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 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements for dealing with complaints and for responding to allegations of abuse appear to support the protection of residents’ rights. EVIDENCE: It was noted that the complaints procedure contained within the home’s service user guide and residents’ files relates to making a complaint against the Commission for Social Care Inspection and that the procedure set out is incorrect. The registered manager stated that she would ensure the correct procedure is made available to residents and their representatives. Records indicate that the home has received three complaints since the date of the last inspection and that it appears to have taken appropriate action as a result. The home has a copy of the local multi-agency policies and procedures on the protection of vulnerable adults. The registered manager is aware of the action to be taken in the event of an allegation of abuse. Gwendolen Lodge Residential Home DS0000066523.V305995.R02.S.doc Version 5.2 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 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with comfortable surroundings in which to live. Action should be taken to minimise the odour arising from the home’s cats. EVIDENCE: The parts of the home that were inspected were decorated and furnished to a satisfactory standard. Residents stated that they are happy with the accommodation and that the premises are kept clean. An odour emanating from the home’s two cats was noticeable in a number of the communal areas on the ground floor. New storage heaters and covers have been fitted since the date of the last inspection. Gwendolen Lodge Residential Home DS0000066523.V305995.R02.S.doc Version 5.2 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing arrangements are generally well managed. EVIDENCE: Residents stated that they are happy with the care they receive from staff members. They reported that the latter are kind and patient. Staffing levels comply with the requirements set by the previous regulatory authority. The records relating to two members of staff were inspected. One of them indicated that appropriate pre-employment checks had been carried out. The registered manager stated that she had been told a satisfactory Criminal Records Bureau disclosure had been obtained for the second member of staff. She agreed to obtain written confirmation. The registered manager stated that eight of the fifteen members of care staff have completed National Vocational Qualification level 2. Two members of staff are in the process of completing NVQ level 2 and one level 3. Records indicate that staff members have received training on issues relevant to their work. Gwendolen Lodge Residential Home DS0000066523.V305995.R02.S.doc Version 5.2 Page 16 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, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Whilst the home appears to be generally well managed, issues relating to quality assurance need to be addressed. EVIDENCE: The registered manager has completed a NVQ level 4 in management & care. She stated that she has not attended any training since the change of ownership but that the forthcoming recruitment of a member of administrative staff would enable her to attend courses. The registered manager stated that the Responsible Individual (a representative of the company) visits the home on a regular basis. Reports of those visits were not however available for inspection. The registered manager stated that the company had yet to conduct a survey of the views of residents or their representatives. Gwendolen Lodge Residential Home DS0000066523.V305995.R02.S.doc Version 5.2 Page 17 The home maintains records of any money it handles on behalf of residents. Two members of staff sign each entry and receipts are kept. Staff members have received training in first aid, fire safety, food hygiene and moving and handling. The registered manager stated that she was in the process of arranging training for those staff members whose qualifications are due for renewal. Records indicate that fire tests and drills have been completed at the required frequency. Gwendolen Lodge Residential Home DS0000066523.V305995.R02.S.doc Version 5.2 Page 18 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 2 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Gwendolen Lodge Residential Home DS0000066523.V305995.R02.S.doc Version 5.2 Page 19 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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 5 Refer to Standard OP3 OP12 OP26 OP33 OP33 Good Practice Recommendations Assessment practices should be reviewed to ensure that all needs are identified prior to a resident’s admission. The programme of activities should be reviewed to ensure that it meets residents’ expectations. Action should be taken to minimise the odour arising from the home’s cats. The registered provider should comply with the requirements of Regulation 26. The registered provider should seek to involve residents and their representatives in reviewing the quality of care provided at the home. Gwendolen Lodge Residential Home DS0000066523.V305995.R02.S.doc Version 5.2 Page 20 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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 Gwendolen Lodge Residential Home DS0000066523.V305995.R02.S.doc Version 5.2 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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