Inspection on 01/11/05 for Herrick Lodge

This inspection was carried out on 1st November 2005.

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

The inspector 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

Herrick Lodge 15/01/09

Herrick Lodge 18/01/07

Herrick Lodge 07/10/04

Herrick Lodge 23/06/04

Herrick Lodge 11/11/03

Similar services:

Applegarth

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

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

CARE HOMES FOR OLDER PEOPLE Herrick Lodge 28 Orchardson Avenue Leicester Leicestershire LE4 6DP Lead Inspector Rajshree Mistry Unannounced Inspection 1st November 2005 09:45 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 Herrick Lodge DS0000038397.V261538.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Herrick Lodge DS0000038397.V261538.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Herrick Lodge Address 28 Orchardson Avenue Leicester Leicestershire LE4 6DP 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 2531304 Leicester City Council Mr Ramesh Bhawsar Care Home 40 Category(ies) of Dementia - over 65 years of age (20), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (20), Old age, not falling within any other category (40), Physical disability over 65 years of age (10), Sensory Impairment over 65 years of age (10) Herrick Lodge DS0000038397.V261538.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service User Numbers DE(E) or MD(E) No one falling within category DE(E) or MD(E) may be admitted into the home when 20 persons who fall within categories/combined categories DE(E) or MD(E) are already accommodated within the home To be able to admit the named person of category DE named in variation application dated 28th November 2002. Service User Numbers PD(E) No one falling within the category PD(E) may be admitted into the home where there are 10 persons of category PD(E) already accommodated within the home Service User Numbers SI(E) No one falling within the category SI(E) may be admitted into the home where there are 10 persons of category SI(E) already accommodated within the home 19th April 2005 2. 3. 4. Date of last inspection Brief Description of the Service: Herrick Lodge Residential Home is a care home providing care for up to forty older people. The home is owned and managed by Social Services, Leicester City Council. Herrick Lodge is large purpose built property, set in a residential setting close to the centre of Leicester. Accommodation is on the ground and first floor and accessible by the stairs or the passenger lift. The home consists of several small and large lounges on the ground and first floor, dining room, designated smoking lounge, prayer room and temple room. Bedrooms are located on both floors with sufficient numbers of bathrooms/shower and toilets facilities. All areas of the home are accessible for people using walking aids and wheelchairs and the surrounding garden area. The home is within walking distance to public transport and five minutes to the city centre. The home is close to a number of places of worship, community facilities, shops and amenities. Herrick Lodge DS0000038397.V261538.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection of the service, which took place on the morning of 1st November 2005 and lasted over 3 hours. This is the second regulatory inspection of the service addressing the remaining core standards. The focus of inspections undertaken by the Commission of Social Care Inspection is upon the outcomes for the resident and their views of the service provided. The primary method of inspection used was ‘case tracking’, following the receipt of the pre-inspection questionnaire. Four residents were identified and their care received was tracked through a review of their records, discussion with the residents, their relative, the care staff and observation of care practices. There was an opportunity to observe the staff and the visiting Community Nurse providing care to the residents. What the service does well: What has improved since the last inspection? Since the last inspection the following improvements have taken place: • • • New carpets in the upstairs corridors and in some bedrooms. The shift times have been changed to allow for two timely handover meetings instead of staggered handovers. Care plans have been improved in consultation with the residents, which now reflect the individual choice of lifestyle, preferences and interests. DS0000038397.V261538.R01.S.doc Version 5.0 Page 6 Herrick Lodge • • New night carers have been recruited and are currently undertaking induction training. Seven staff are scheduled to commence training in the ‘Certificate in Dementia Awareness’ course. 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. Herrick Lodge DS0000038397.V261538.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Herrick Lodge DS0000038397.V261538.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6. EVIDENCE: The home does not provide intermediate care. Herrick Lodge DS0000038397.V261538.R01.S.doc Version 5.0 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, 9 Residents are well looked after having their choice of lifestyle, health and social care needs met. EVIDENCE: Four residents tracked were spoken with and their individual care plans and risk assessments were examined. Two out of the four care plans were in good order, demonstrating the residents had been involved and consulted and care plans reflecting the individuals’ wishes. Risk assessments were in place and there was evidence to suggest care plans were being reviewed. The terminology used in the care plans such as “reasonable” was discussed with the Registered Manager as this clearly did not define the level of assistance required. There was also evidence to suggest in the communication book and from discussion, that instructions left by the home’s management team had not been actioned, resulting in an incomplete care plan for a new resident admitted to the home over a week. Assurance was given by the Registered Manager that these would be addressed. The medication storage viewed was found safe and supported by good management systems for ordering, storing, recording and returning medication. Residents received their medication promptly by trained senior Herrick Lodge DS0000038397.V261538.R01.S.doc Version 5.0 Page 10 staff. Medication and respective records were examined for four residents found in good order and up to date. Management of controlled medication was in good order. Herrick Lodge DS0000038397.V261538.R01.S.doc Version 5.0 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): 13, 14, 15. All residents are able to maintain contact with families and friends. The home offers a good choice of meals to suit any special dietary needs. EVIDENCE: Family and friends can visit at any time and are made welcome. On the day of the inspection, several visitors were seen meeting with their relative, celebrating Diwali, the festival of lights or chatting. Residents spoken with confirmed they are encouraged and supported to maintain contact with family and friends and accessing facilities in the community. The home celebrated by having a Diwali Party on 29th October 2005, where residents’ invited their family and friends. Residents have been encouraged and supported to practice and observe religious practices such as going to the temple or Holy Communion at the home. Residents spoken with confirmed staff support them to make daily choices and pursue interests. The Registered Manager has made contact with the newly opened “Peoples Centre”, resource for the community, which would be available to the residents. The menu on the day of inspection was viewed and showed a choice of nutritionally balanced meals accommodating special dietary requirements. The home has two separate kitchens catering for Asian/vegetarian and English Herrick Lodge DS0000038397.V261538.R01.S.doc Version 5.0 Page 12 style meals. On the day of the inspection the home prepared a special meal as some residents were celebrating Diwali. Residents spoken with were all satisfied with the variety and selection of meals offered, prepared appropriately and fresh vegetables and fruits available. Meals are served in the dining room or residents can choose to eat in their own rooms. Comments included “offered really good meals, enjoy both English and Asian meals”; “I do like spicy food but it doesn’t agree with me” and “prefer streaky bacon and 1 fried egg for breakfast cooked my way”. Herrick Lodge DS0000038397.V261538.R01.S.doc Version 5.0 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 Arrangements for receiving and responding to complaints are satisfactory, resulting in protection of residents’ rights. EVIDENCE: Residents receive a copy of the home’s complaints procedure at the point of admission, which is in the ‘service user guide’. The complaints procedure in available in large print, different languages and other formats. Residents spoken with were aware of whom to contact and speak with should they have any concerns. Residents and relative spoken with were aware of whom to contact and were confident that concerns and complaints made would be addressed promptly. Most residents spoken with said they felt there was no reason to complain and comments included: “Living here is enjoyable” “The people here are very, very good to me!” Herrick Lodge DS0000038397.V261538.R01.S.doc Version 5.0 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): 26. Residents live in a safe, homely and well-maintained environment that is kept clean and tidy. EVIDENCE: The home is safe and well maintained with adaptations to suit residents’ specific needs. It is decorated and furnished to a good standard that creates a comfortable environment that is supported by the maintenance person. Since the last inspection several bedrooms and the corridor on the first floor have had new carpets. During the inspection the service, the Environmental Health Officer conducted an unannounced inspection of the kitchen and indicated the home was compliant with the regulations. The home was clean and tidy. Residents spoken with were very satisfied with the cleanliness of the home. Comments received included the “As far as the home – I think it’s 100 ”. Staff were observed wearing protective clothing when carrying out personal care tasks. The Inspector spoke with the laundry staff describing the procedures followed ensuring compliance with COSHH, health and safety and preventing the spread of infection. Herrick Lodge DS0000038397.V261538.R01.S.doc Version 5.0 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): 28, 29. Residents are protected by the home’s robust recruitment procedures. EVIDENCE: The recruitment procedure is robust and in accordance with the local authority procedures based on equal opportunities, which is managed by the Human Resource Team. Staff personnel files containing the application forms and preemployment checks are held at the Human Resource Office and the Registered Manager receives confirmation the pre-employment checks carried out are satisfactory. This was viewed for the two new staff recently appointed and currently completing the induction training and deemed satisfactory. Staff training records are maintained on individual personal development files, which contained evidence of the comprehensive induction and training undertaken. The Registered Manager acknowledged that training records are not all in good order and steps are being taken to input this information on the database to effectively monitor the staff training and skill mix. This would be viewed at the next inspection. Seven members of staff have been identified and due to commence training ‘Dementia Awareness’ over a period of 14 weeks. At present the home has seven staff qualified at National Vocational Qualification level 2 and four in the process of completing this level. Herrick Lodge DS0000038397.V261538.R01.S.doc Version 5.0 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): 35 The residents’ finances are safeguarded with a robust system. EVIDENCE: Records of residents’ valuables are accurately detailed. Residents manage their own finances with either support from a relative or solicitors, as appropriate. Residents finance records examined were clearly showed good financial reconciliation and management of residents money, which is double signed and cross-checked against the sums of money kept on behalf of the resident. Residents indicated that their money was available to them when needed. Herrick Lodge DS0000038397.V261538.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X X X X X X X X 3 STAFFING Standard No Score 27 X 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X X Herrick Lodge DS0000038397.V261538.R01.S.doc Version 5.0 Page 18 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 Refer to Standard OP7 Good Practice Recommendations The Registered Person should ensure that care plans and risk assessments should be in place and reviewed to reflect the individuals needs, using clear terminology that is not open to interpretations and The Registered Person should ensure that instructions and delegated tasks are followed up and monitored to ensure residents’ needs are met timely. 2 OP7 Herrick Lodge DS0000038397.V261538.R01.S.doc Version 5.0 Page 19 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. 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