Inspection on 31/10/05 for Heath Lodge

This inspection was carried out on 31st October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Heath Lodge 02/03/10

Heath Lodge 29/01/09

Heath Lodge 22/01/08

Heath Lodge 11/07/06

Heath Lodge 05/07/05

Heath Lodge 29/09/04

Heath Lodge 13/04/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Heath Lodge St George Avenue Weybridge Surrey KT13 0DA Lead Inspector Damian Griffiths Announced 31st October 2005 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 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. Heath Lodge H58 - H09 s13668 Heath Lodge v247598 311005 Stage 0 ann.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Heath Lodge Address Heath Lodge, St Georges Avenue, Weybridge, Surrey, KT13 0DA Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01932 853680 Dr Ajit Prasad, Mrs Nishi Prasad Dr Ajit Prasad, Care home only (PC) 26 Category(ies) of Old age, not falling within any other category registration, with number (OP) 16 of places Dementia - over 65 years of age DE(E) 10 Heath Lodge H58 - H09 s13668 Heath Lodge v247598 311005 Stage 0 ann.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1:The age/age range of the persons to be accommodated will be: 65 years and over. Date of last inspection 27th September 2005 Brief Description of the Service: Heath Lodge is a registered care home for up to 26 older people. It is one of three homes owned by Surrey Rest Homes Ltd.The home is a large detached house with a purpose built extension, set in a large garden in a residential road close to Weybridge railway station and town.The accomodation is on two floors with a chair-lift that falls short of the last few steps to the ground floor. The home has single and double rooms, some with en-suite facilities. There is a garden to the rear of the premises and parking to the front of the building. Heath Lodge H58 - H09 s13668 Heath Lodge v247598 311005 Stage 0 ann.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The announced inspection took place over a 6-hour period and was the third inspection of the Commission for Social Care Inspection year April 2005 to March 2006. Lead Inspector Damian Griffiths was assisted throughout the inspection by the Registered Manager Mr Ajit Prasard and the new Manager (yet to be registered) Mrs Maria Hogg representing the establishment. Four residents and three members of the staff team were able to contribute to this inspection report. Resident’s representatives completed four comment cards and residents completed a further two before the inspection and these comments are included in this report. Heath Lodge was also able to provide a pre-inspection report. The inspector was able to discuss resident’s health care and the homes response with a health care practitioner. The inspector would like to thank the residents, manager, health care practitioners and staff for their assistance and hospitality during the inspection. It is recommended that the reader should also look at the previous report that can be accessed by using the CSCI website details on the last page of this report. What the service does well: What has improved since the last inspection? Care plans were clear and easy to read and contained a good range of information although some areas needed to be extended. Heath Lodge H58 - H09 s13668 Heath Lodge v247598 311005 Stage 0 ann.doc Version 1.40 Page 6 Residents are benefiting from care plan reviews and currently undergoing a health care re-assessment from the GP attached to the home and other health practitioners who enjoy a good relationship with staff and residents. Resident’s benefit from more focused daily activities although more work needs to be done. Staff were aware of the adult protection policies. A specialised washing machine with sluice facility and a spin dryer have been installed and a shower room refit has been completed. Staff had received regular supervision and a new manager had been recruited. The new manager will be required to show evidence of her level of NVQ training as a matter of course within the registration procedure. 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. Heath Lodge H58 - H09 s13668 Heath Lodge v247598 311005 Stage 0 ann.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Heath Lodge H58 - H09 s13668 Heath Lodge v247598 311005 Stage 0 ann.doc Version 1.40 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 standard(s) 3 and 7. There have been no new admissions since June 2005 due to the need to review their systems of recording. Care plans are being reviewed and remain incomplete but are much easier to read. EVIDENCE: Four care plans were inspected and all included completed assessments. The last resident to be admitted to the home had received a complete assessment of need that included the involvement of family and health and social care practitioners. Care plans for residents with dementia needs are currently under review and residents are benefiting from GP and Psychiatric health care assessment. The review process is expected to conclude within the agreed timescale by the end of December. Please see the requirement section of this report. Heath Lodge H58 - H09 s13668 Heath Lodge v247598 311005 Stage 0 ann.doc Version 1.40 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 standard(s) 7, 8, 9 and 10 Care Plans were in need of more detailed risk assessments. Residents’ benefit from regular contact with health care practitioners. Policy and procedures for medication were not being followed closely enough however residents were treated with respect and dignity. EVIDENCE: Risk assessments were in place but were not prescriptive enough. Diagrams indicating cuts, pressure sores or abrasions did not adequately inform the reader of what action was required or the outcome. Residents receive regular health care checks and were benefiting from the established method of communication with the community healthcare practitioners. The health care needs were not above normal expectations. These included, blood pressure and tissue viability checks and blood tests. Medication procedures and practice were inspected and an inspection of the medicine cabinet was conducted. This revealed a selection of drugs that had been made ready for disposal. The medication had been stored without the knowledge of senior staff and were out of date from June 2005. There was no Heath Lodge H58 - H09 s13668 Heath Lodge v247598 311005 Stage 0 ann.doc Version 1.40 Page 10 entry on the MAR sheets available at the time to establish the details of this action. Residents and their representatives consulted stated that they were treated with respect and privacy was available at the home when required. Please see the requirement section of this report. Heath Lodge H58 - H09 s13668 Heath Lodge v247598 311005 Stage 0 ann.doc Version 1.40 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 standard(s) 12,13,14 and 15. Residents enjoy a range of indoor activities but those consulted stated that this could be improved. Family and friends were always welcome to visit and residents were able to discuss issues that affect them at the home on a regular basis with the management. Residents were satisfied with the daily menu selection available. EVIDENCE: Activities were prominently listed on the wall outside the office and residents were engaged in a Halloween party and themed games during the inspection. The activities have improved since the first annual inspection but communication with residents needs to be improved and documented on a daily basis within the care plan. One resident consulted, a known lover of craftwork was not aware of the weekly craft activity available to residents his care plan did not list this as regular activity and confirmed that he had not been given the opportunity to attend. Other resident’s comments indicated that more consultation was required. The home has indicated that a member of staff would become a social activities co-ordinator with specific time allocated. Heath Lodge H58 - H09 s13668 Heath Lodge v247598 311005 Stage 0 ann.doc Version 1.40 Page 12 Family and friends consulted were satisfied with their level of access at the home and confirmed that they were always made welcome this was observed at the time of the inspection. Residents participate in a monthly meeting with managers and staff of the home to discuss issues of importance to them. The October minutes were in evidence and showed that issues relating to food, activities and the good quality of staff care were discussed and actions were listed. There was a choice of two meals daily and the provision of menus that are attached to the resident’s service user guides and available in each resident’s rooms. Fresh fruit was available in the dining room. Residents will be deciding if changes to menus and the way food is served are required at the next residents meeting. Please see the requirement section of this report. Heath Lodge H58 - H09 s13668 Heath Lodge v247598 311005 Stage 0 ann.doc Version 1.40 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 standard(s) 16 and 18. Residents and their representatives were aware of the complaints process and staff were also aware of adult protection policies and procedures. EVIDENCE: Comments received from relatives showed that most were aware of the complaints procedures or had not needed to make a complaint. One relative consulted had made a complaint and confirmed that she had received a satisfactory outcome and that the management had been open and cooperative. Residents were aware of whom to contact if unhappy with the care they received. There was one complaint received by the home, which has not been fully resolved and the Commission for Social Care Inspection awaits the outcome. Staff consulted were aware of adult protection and regular risk assessment recording was in place. Adult protection training was available and had been received by staff consulted and they were also aware of the whistle blowing procedures. The Surrey Multi-agency procedure for adult protection was available and situated in the office. Heath Lodge H58 - H09 s13668 Heath Lodge v247598 311005 Stage 0 ann.doc Version 1.40 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 standard(s) 19,20 ,21 and 26. The premises were fit for purpose, improvements had been implemented and residents had access to safe indoor communal facilities that were clean and tidy. EVIDENCE: A tour of the premises was conducted and two lounges were available to the residents who were engaged in a variety of activities and relaxation throughout the day. Both rooms were well lighted and well presented clean and fresh. Residents appeared comfortable within their surroundings. The stair lift was correctly stored and was still under warranty. A bathroom had been refurbished and situated on the ground floor, a new walk-in bath had fitted, the hall, an empty residents bedroom and a residents bathroom on the first floor had been redecorated and a new sluice washing machine and washing dryer installed. The television has also been equipped with a freeview top box to improve the picture quality. Heath Lodge H58 - H09 s13668 Heath Lodge v247598 311005 Stage 0 ann.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 29 and 30. Recruitment practices were generally good but did not meet requirements. Training experience for the nightshift on the week of inspection were shown to be inadequate. EVIDENCE: Staff employment details were inspected and the majority of files were in order however the employment history of one file was incomplete and did not comply with schedule 3 of the (Care Standards Act 2001). Copies of staff job descriptions were in evidence. The staff rota was inspected and staff files of those listed on night duty for the week were inspected to confirm their level of training. Evidence of staff training included: Protection of Adults, Safe Handling of Medication, Food Hygiene and Fire Safety. It was agreed that the staff were lacking a current first aider to ensure the safety of residents at all times. In-house, accredited, training for People Handling and Risk Assessment was available from the homes former administrator. Please see the requirement section of this report. Heath Lodge H58 - H09 s13668 Heath Lodge v247598 311005 Stage 0 ann.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,36 and 38. There is a new manager in post and staff supervision was in evidence. Health and safety policy practices were in evidence and staff were given training in all aspects of health and safety to protect the residents and themselves. EVIDENCE: The new manager in post has applied for registration with the commission. She is currently undertaking her level 4 registered managers award. During the inspection the home was being run efficiently and communications between staff were very good and polite. Three staff members were consulted and confirmed they had regularly received formal supervision and all had received supervision within the last month. No health and safety issues were observed or reported, all relevant procedures were available and staff received training in these areas. RIDDOR procedures had been completed and all appropriate reports had been submitted. Heath Lodge H58 - H09 s13668 Heath Lodge v247598 311005 Stage 0 ann.doc Version 1.40 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 x x x x 3 STAFFING Standard No Score 27 x 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x x x x 3 x 3 Heath Lodge H58 - H09 s13668 Heath Lodge v247598 311005 Stage 0 ann.doc Version 1.40 Page 18 Yes Are there any outstanding requirements from the last inspection? 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 (1) 15 (2) (a) (b) (c) (d0 Requirement Timescale for action 31/12/05 2. OP7 13 (4) (b) 14 (1) (a) 3. OP9 13 (2) 4. OP12 15 The registered manager must ensure that all residents have a comprehensive care plan drawn up with each resident involved to ensure that all aspect of the health care ,personal and social care needs are recorded and regularly reviewed: Requirement since 26/05/06 new timescale agreed. The registered manager must 31/12/05 ensure that the residents care plan meets relevant clinical guidelines, which includes a risk assessment and a falls risk assessment. This was the second time this requirement has been made. A new timescale was agreed. The registered manager must 31/12/05 ensure that used medication is safely disposed and that staff adhere to the policy and procedures of the home. The registered manager must 31/12/05 ensure that social activities and interests are recorded in the care plans on a daily basis. This is the second time this requirement has been made. A new timscale has been agreed Version 1.40 Heath Lodge H58 - H09 s13668 Heath Lodge v247598 311005 Stage 0 ann.doc Page 19 5. OP29 19 (1) (b)sched (2) 18(2)(a) 6. OP30 7. OP31 19(5)(b) 31/12/05 The registered manager must ensure that Schedule 2 of the Care Standards Act is followed when recruiting staff. The registered manager must 01/12/05 ensure that staff recieve structured induction training and in particular first aid training be acheived by at least one member of staff on each shift. The registered manager must 31/12/05 ensure that management and all staff have qualifications suitable to the post. 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. Refer to Standard Good Practice Recommendations Heath Lodge H58 - H09 s13668 Heath Lodge v247598 311005 Stage 0 ann.doc Version 1.40 Page 20 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Heath Lodge H58 - H09 s13668 Heath Lodge v247598 311005 Stage 0 ann.doc Version 1.40 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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