Inspection on 16/08/05 for Horsell Lodge

This inspection was carried out on 16th August 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

Horsell Lodge 04/11/08

Horsell Lodge 22/05/07

Horsell Lodge 28/11/05

Horsell Lodge 15/06/04

Similar services:

Old Hastings House

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Horsell Lodge Kettlewell Hill Horsell Woking, Surrey GU21 4JA Lead Inspector Janet Daulton Announced 16 August 2005 10:00am 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. Horsell Lodge H58 H09 s13682 Horsell Lodge v231336 160805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Horsell Lodge Address Kettlewell Hill Horsell Woking Surrey GU21 4JA 01483 760706 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) Horsell Lodge Limited Kate Gilbert CRH Care Home 46 Category(ies) of DE(E) Dementia - over 65 - 8 registration, with number MD(E) Mental Disorder - over 65 - 8 of places OP Old Age - 46 PD(E) Physical Disability - over 65 - 6 SI(E) Sensory Impairment - over 65 - 6 Horsell Lodge H58 H09 s13682 Horsell Lodge v231336 160805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Of the 46 older people accommodated up to 8 may be in the category MD(E) and/or DE(E) - Date Implemented 1 April 2002 Of the 46 older people accommodated up to 6 may be in the category PD(E) and/or SI(E) Date Implemented 17 May 2002 All residents to be over 65 years - Date Implemented 1 April 2002 Date of last inspection 25 January 2005 Brief Description of the Service: Horsell Lodge is a large residential home providing care for 46 older people,up to 8 with dementia, and 6 with a physical disability.THe home is situated in Horsell, which is near to the large town of Woking. Local shops and public transport are nearby. The accomodation is arranged on three floors, with a passenger lift accessing all floors.The accommodation consists of thirty six single rooms, of which twent four have ensuite facuilities. There are five diouble rooms, all with ensuite facilities. There are several communal areas,together with a number of quiet areas within the home. The home is situated in substantial grounds, and there are adequate parking facilities within the gtrounds. Horsell Lodge H58 H09 s13682 Horsell Lodge v231336 160805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over 4.5 hours and was the first inspection carried out by the Commission for Social Care Inspection for the year 2005-2006. The inspection was carried out by Mrs. J Daulton, Lead inspector for the service. The Manager Mrs. K. Gilbert was present for all of the inspection. The Regulation Manager for the company, Ms J. Innes, and the Regional Manager Ms. J. Mason attended for part of the inspection. A tour of the premises took place. Five care plans, the complaints log, staff recruitment files, and a sample of safety certificates were inspected. The inspector spoke to twenty-three service users during the day. The inspector also spoke with some of the staff on duty at the time of the inspection. The inspector had received written feedback from six service users, five relatives/visitors, and from one Social Services Care Manager. This was a positive inspection, and the feedback from service users and relatives was generally very complimentary. The inspector would like to thank the staff and service users for their time, assistance, and hospitality during the inspection. What the service does well: The home continues to provide a homely and attractive environment for the service users. The staff were seen to be caring for the service users in a friendly and respectful way. All service users contacted stated that they felt safe and well cared for in the home. Service users were encouraged to maintain control over their daily life as much as possible. Meals were varied, well balanced and nicely presented, offering a choice and variety. The service users care plans were detailed. They gave clear instructions to the staff about the service users needs and the care that had to be given to meet those needs. Horsell Lodge H58 H09 s13682 Horsell Lodge v231336 160805 Stage 4.doc Version 1.40 Page 6 There were adequate opportunities for service users to take part in activities inside and outside of the home. 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. Horsell Lodge H58 H09 s13682 Horsell Lodge v231336 160805 Stage 4.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 Horsell Lodge H58 H09 s13682 Horsell Lodge v231336 160805 Stage 4.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) 3,4,6 Service users had their needs assessed before they moved into the home to ensure that the home could provide for those needs. Staff received appropriate training to enable them to care for service users with specific needs. EVIDENCE: All the care plans inspected had a pre- admission needs assessment completed by the Manager of the home, or the Social Services Care Manager. The assessment covered all elements of physical, mental, and social needs. There was evidence of appropriate training, including dementia awareness training, and caring for service users with sensory impairment. The home accesses local organisations, such as Surrey Care Association for training. The home does not provide intermediate care. Horsell Lodge H58 H09 s13682 Horsell Lodge v231336 160805 Stage 4.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) 7,8,9,10, The service users health, personal and social needs were set out in an individual plan with all the needs clearly identified and there was documentary evidence of the identified needs being met. Medication procedures and practice were satisfactory. Service users were treated with respect by the care staff. EVIDENCE: Service users and visitors spoken with were very complimentary about the care that they received at the home. Comments included “staff are very gentle and kind”, and “ I couldn’t have made a better choice for a home”. The five care plans randomly selected and inspected were very detailed and clearly set out the actions which needed to be taken by the care staff to make sure that all aspects of the health, personal and social care needs were met. All the care plans were signed by the service users to indicate that they were consulted when drawing up the care plans, and they were reviewed regularly. Staff were observed treating the service users in a friendly, and professional way. Service users were registered with local GPs and confirmed that they could see a GP if they wished. Service users also confirmed that they had access to hearing and sight tests where necessary. Horsell Lodge H58 H09 s13682 Horsell Lodge v231336 160805 Stage 4.doc Version 1.40 Page 10 Medication records were examined. Medication was being stored and administered in accordance with the homes policies and procedures. The Manager of the home or Regional trainer provided training for staff in safe administration of medication. Several service users were self-medicating and arrangements were in place for them to store their medication safely, and risk assessments were completed. A recommendation was made that the homes self-administration policy provides information on how often the risk assessment should be carried out. Horsell Lodge H58 H09 s13682 Horsell Lodge v231336 160805 Stage 4.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) 12,13,14,15, The social and recreational activities were varied and appropriate. Service users were able to maintain contact with families and friends. The catering arrangements and facilities were satisfactory. EVIDENCE: An activity organiser had recently been appointed, and she organised a programme of activities. Several service users stated that they enjoyed joining in the activities, and a quiz was being held in the conservatory area on the day of the inspection. In the afternoon an entertainer played music in the main lounge. Spiritual needs were supported by regular visits from clergy from Anglican and Roman Catholic Churches. Service users confirmed that visitors were welcome at the home. The home had a new chef, who had been working in the home for three months. Feedback from the service users about the quality and variety of the food was generally positive. On the day of the inspection the lunch served was well presented and appeared nutritious, and a choice was available. Most of the service users have their financial matters dealt with by their relatives. Horsell Lodge H58 H09 s13682 Horsell Lodge v231336 160805 Stage 4.doc Version 1.40 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 The home had a simple, clear and accessible complaints procedure, which included timescales for the process. The homes policy for dealing with allegations of abuse was in line with Surreys Multi - agency procedures. EVIDENCE: The home had a complaints procedure, which was displayed, in the home. A complaints file was kept. The home has had 6 complaints during the last 12 months, 5 verbal complaints and 1 written complaint. These were seen to be dealt with appropriately. The service users stated that they would complain to the manager of the home without fear of recriminations. All staff had received vulnerable adults training and when questioned by the Inspector were knowledgeable about what constituted abuse of service users, and the action that they must take. Horsell Lodge H58 H09 s13682 Horsell Lodge v231336 160805 Stage 4.doc Version 1.40 Page 13 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) 19,26 The location and layout of the home was suitable for its stated purpose. It was accessible, safe, and well maintained with a pleasant and homely atmosphere. EVIDENCE: During a tour of the home the premises were seen to be well maintained with service users able to access all areas of the home and gardens. On the day of the inspection the home was found to be warm and bright with a homely atmosphere and a satisfactory standard of housekeeping and cleanliness. The garden areas were pleasant. The outside of home was being decorated on the day of the inspection. There was a programme of routine maintenance in the home, and the home employed a full time maintenance man. The home had infection control policies, and staff were seen to carry out good basic infection control measures when caring for the service users. The Horsell Lodge H58 H09 s13682 Horsell Lodge v231336 160805 Stage 4.doc Version 1.40 Page 14 manager informed the Inspector that the budget for the year included the purchase of 2 automatic sluice machines. The home had purchased two new clothes washing machines. Horsell Lodge H58 H09 s13682 Horsell Lodge v231336 160805 Stage 4.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) 27,29,30 The numbers and skill mix of the staff met the service users needs. Service users were protected by the homes procedures for recruitment. EVIDENCE: The staff rota inspected demonstrated that the staffing numbers and skill mix were appropriate to meet the assessed needs of the service users living in the home. Domestic and laundry staff were employed. All interactions observed between staff and service users during the inspection were seen to be caring and respectful. Two staff files were examined. The recruitment files were well organised. All necessary checks had been completed prior to employment, and staff received Statements of Terms and Conditions. Records of training evidenced that staff received induction training after employment. Horsell Lodge H58 H09 s13682 Horsell Lodge v231336 160805 Stage 4.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) 35,38 There were policies in place in the home to ensure that, as far as is reasonably possible, service users are protected. EVIDENCE: Financial records of the service users were in place and a random check showed these to be in order. Written records of financial transactions were maintained. Health and safety records were sampled, including moving and handling training, fire drill and fire safety checks, and gas and electrical certificates. These were all in order. The home has appointed first aiders, and a record was kept of any incidents or accidents. The manager holds regular Health and Safety meetings with appropriate staff members, the last meeting was held in June 2005. Horsell Lodge H58 H09 s13682 Horsell Lodge v231336 160805 Stage 4.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 x x 3 3 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x x x x 3 Horsell Lodge H58 H09 s13682 Horsell Lodge v231336 160805 Stage 4.doc Version 1.40 Page 18 no 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 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. Refer to Standard 9.2 19. Good Practice Recommendations The homes self administration policy provides information on how often the risk assessment should be carried out. The home replaces the manual sluices with automatic ones. Horsell Lodge H58 H09 s13682 Horsell Lodge v231336 160805 Stage 4.doc Version 1.40 Page 19 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 Horsell Lodge H58 H09 s13682 Horsell Lodge v231336 160805 Stage 4.doc Version 1.40 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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