Inspection on 20/12/05 for Laburnum Lodge

This inspection was carried out on 20th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Laburnum Lodge 18/01/10

Laburnum Lodge 28/10/09

Laburnum Lodge 16/06/09

Laburnum Lodge 13/01/09

Laburnum Lodge 26/06/08

Laburnum Lodge 03/07/07

Laburnum Lodge 03/01/07

Laburnum Lodge 30/05/06

Laburnum Lodge 22/06/05

Laburnum Lodge 16/11/04

Laburnum Lodge 12/07/04

Laburnum Lodge 28/04/04

Laburnum Lodge 21/01/04

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Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Laburnum Lodge 2a Victoria Street Littleport, Ely Cambridgeshire CB6 1LX Lead Inspector Mrs Jenny Cangy Unannounced Inspection 20th December 2005 11:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Laburnum Lodge DS0000015120.V263295.R01.S.doc Version 5.1 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. Laburnum Lodge DS0000015120.V263295.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Laburnum Lodge Address 2a Victoria Street Littleport, Ely Cambridgeshire CB6 1LX 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) 01353 860490 01353 860490 Dr A Hassaan Mrs S Hassaan Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Laburnum Lodge DS0000015120.V263295.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 22nd June 2005 Brief Description of the Service: Laburnum Lodge is a two-storey house, that includes a single storey extension, to provide accommodation, personal care and support for a maximum number of 16 places for individuals over 65 years of age. The upper floor is access via stairs or a stair lift. The home is situated in the centre of the village of Littleport and is close to shops, cafes, pubs and local amenities. A garden is available to the rear of the building. Laburnum Lodge DS0000015120.V263295.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection commenced at 11.00 with the acting manager. Time was spent in the office reviewing the requirements from the last inspection and checking standards not inspected at that time. Some records were inspected and a general discussion regarding the management of the home took place. The inspector was present in the home over lunch time and it was noted that staff had the same menu as the residents which they ate after all the service users had finished their lunch and were settled. A general discussion with staff took place as they ate their lunch. A tour of the home followed and service users and visitors were spoken to and voiced their satisfaction with the care and homely surroundings. The home was decorated for Christmas and a programme of Christmas activities was in place. Daily activities take place each afternoon with a specific member of staff who arrived for the days session while the inspection was in progress. The home was found to be fresh and clean throughout. Any standards not inspected on this visit were met at the last inspection. It should be noted that the home has been without a registered manager since January 2005. What the service does well: What has improved since the last inspection? A new bath hoist has been fitted in the ground floor bathroom. The statement of purpose has been updated to reflect the current staffing of the home. The acting manager has rearranged the shift patterns to overlap one day carer with the night carer so two staff are available to assist service users to bed and enable them to stay up later if the wish. An additional domestic has been employed and an activities person is in the home each afternoon doing structured activities. Annual quality assurance monitoring questionnaires are sent to relatives and service users. The staff payroll is now automated and staff do not have the risk of collecting large amounts of money from the bank. Staff training is ongoing with the majority of the staff having or working toward NVQ level 2 in care. Laburnum Lodge DS0000015120.V263295.R01.S.doc Version 5.1 Page 6 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. Laburnum Lodge DS0000015120.V263295.R01.S.doc Version 5.1 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 Laburnum Lodge DS0000015120.V263295.R01.S.doc Version 5.1 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): 1, 2, & 4 Service users have the information they need to make an informed choice about moving into Laburnum Lodge. They are assured their needs can be met. EVIDENCE: There is an up to date informative service user guide and statement of purpose and all service users have a written contract of terms and conditions of residence. All prospective service users have an assessment of needs by a senior member of staff before moving into the home and a letter of acceptance is sent stating their needs can be met. The acting manager does not accept any service users outside of the registration category of older people. Laburnum Lodge DS0000015120.V263295.R01.S.doc Version 5.1 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): 9, 10, &11 Service users are treated with respect and dignity at all times. EVIDENCE: Service users are able to manage their own medication if they are able and wish to. On the day of inspection no service users were doing so. The home has the Lloyd’s monitored dose system of medication which is monitored regularly by the local Lloyds pharmacist who also provides training. All service users are able to lock their rooms if they wish and their privacy and dignity are paramount to the care staff and forms part of their induction training. Shared rooms have portable screens to give privacy. The staff have the information needed to ensure the service users wishes in final illness and after death are respected. Laburnum Lodge DS0000015120.V263295.R01.S.doc Version 5.1 Page 10 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): 14 Service users are able to make choices in all aspects of their lives. EVIDENCE: The service users have a choice of menu at all meals. There are monthly service user meetings where they can express opinions about their life in the home. One outcome of these meetings is bowls of fresh fruit around the home. They are able to personalise their own rooms. It was noted by the inspector that all the service users were in the lounge and established that this was their choice as the enjoyed the homely atmosphere and the company of others. Laburnum Lodge DS0000015120.V263295.R01.S.doc Version 5.1 Page 11 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 Service users have the information to enable them to make a complaint if they need to. EVIDENCE: The complaint procedure is contained in the service users guide. Information regarding contacting other agencies including the CSCI is also contained in the service user guide. There have been no complaints to the home or CSCI since the last inspection. Laburnum Lodge DS0000015120.V263295.R01.S.doc Version 5.1 Page 12 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, 21, 22 On the whole the environment meets the required standards However some attention is needed to the ground floor bathroom flooring. EVIDENCE: The home was clean and fresh throughout and bedrooms pleasant and personalised. Hoists are available and well maintained and specialist equipment is acquired via the community nurses if needed. The flooring in the ground floor bathroom is in need of attention at the area where the old bath hoist was removed has no floor covering and the join in the floor covering has come apart causing a hazard where the surface has lifted. It should be noted that service users do not use this bathroom independently and the hazard is mainly to staff. Laburnum Lodge DS0000015120.V263295.R01.S.doc Version 5.1 Page 13 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, 29 Service users needs are met by the number and skill mix of staff on duty only due to the dedication and goodwill of the staff working in excess of their contracted hours. Service users are protected by the homes recruitment procedures. However long serving staff do not have appropriate contracts or job descriptions. EVIDENCE: The acting manager has restructured the shift pattern to ensure there are 2 staff on duty at all times when service users are up and about and that service users do not have to go to bed before 8 pm. There are 2 care staff on duty from 8 am to 9.30 pm and one waking night staff from 9.30 pm until 8am. From Monday to Friday the acting manager is also on duty from 8.30 am to 4.30 pm. However the staff team employed is not sufficient to maintain these levels without some staff exceeding their contracted hours and the acting manager covering some care and cooking hours. It should also be noted that the acting manager has not been able to take an appropriate amount of annual leave in this year in order to maintain minimum staffing levels Appropriate recruitment procedures are followed and staff issued with job descriptions and terms and conditions of employment. However long serving staff who have changed their role or cover more than one role do not have this reflected in their job description or terms and conditions. The acting manager has only a contract from her original employment as cook despite being deputy manager for over a year and in the role of acting manager for almost a year. Laburnum Lodge DS0000015120.V263295.R01.S.doc Version 5.1 Page 14 Staff are committed to NVQ training in care and the home will meet the required 50 of staff having NVQ level 2 in care or above when the staff currently undertaking the course have completed. Laburnum Lodge DS0000015120.V263295.R01.S.doc Version 5.1 Page 15 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, 32, 33, 34, 35, 36 & 38 The appropriate management of the home causes concern. This is not due to the efforts of the acting manager However the proprietors Mr and Mrs Hassaan are not demonstrating adequate fitness in their roles as registered providers as their commitment to appoint a manager in October and apply to register that person as manager has not been honoured. They have also failed to provide the acting manager with the level of support she needs to ensure all the national minimum standards are met. EVIDENCE: The acting manager is doing an excellent job in maintaining standards in the home but with little appropriate support from the proprietor. The acting manager has completed NVQ level 2 and is planning to start level 3 in January. The acting manager and her team are dedicated and hardworking, ensuring the home is adequately staffed. However it is of great concern that the acting manager has been unable to take more than one weeks holiday and that the proprietor has not ensured she has had an appropriate amount of time off or the remuneration in lieu of annual leave for the extra hours she is on duty in Laburnum Lodge DS0000015120.V263295.R01.S.doc Version 5.1 Page 16 the home. Staff working excessively long hours without adequate time off may affect their health and subsequently compromise the care of the service users. Health and safety checks in the form of recorded water temperatures have not been maintained. The proprietor has failed to identify this omission and rectify it at the required monthly visits to the home. A manager has not been formally appointed despite assurances by the proprietor that this would happen in October 2005. The proprietor has failed to keep the CSCI up to date regarding the management arrangements for the home. The proprietor has failed to provide the CSCI with evidence of the financial viability of the home. The proprietor has failed to notify the CSCI of their absence from the country in excess of 4 weeks and what alternative arrangements have been made to provide cover in their absence. The records required are maintained but the filing system is inadequate. The registered person should create an effective filing system that ensures the confidentiality of records, to make them easily accessible for inspection and to clear the office of clutter. Laburnum Lodge DS0000015120.V263295.R01.S.doc Version 5.1 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 3 3 X 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 2 X 3 3 X X X X STAFFING Standard No Score 27 2 28 2 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 1 3 2 X 2 Laburnum Lodge DS0000015120.V263295.R01.S.doc Version 5.1 Page 18 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard OP19 OP27 Regulation 23(2(b)) 18(1a&cii) Requirement The registered person must ensure all areas of the home are well maintained and hazard free The registered person must review the staffing levels to ensure all staff have suitable assistance to fulfil their role and have adequate time off for training purposes. The registered person must ensure that all staff have an employment contract and job description(s) appropriate to the role(s) they carry out as required by schedule 4 (6(e(ii)))of the Care Homes Regulations The registered person must appoint an appropriate manager and complete an application for their registration with the CSCI. It should be noted that this requirement is outstanding from the last inspection and failure to meet this requirement will result in prosecution. The registered person must ensure that all aspect of the running of the home and DS0000015120.V263295.R01.S.doc Timescale for action 30/01/06 30/01/06 3 OP29 17(2) 30/01/06 4 OP31 8 30/01/06 5 OP32 10 30/01/06 Laburnum Lodge Version 5.1 Page 19 6 OP33 24 7 OP34 25 8 OP36 18(2) 9 OP38 13(4) management and supervision of staff are met. The registered person must ensure that a full quality assurance programme is in place as listed in National Minimum Standard 33 in addition to annual satisfaction surveys. The registered person must provide the CSCI with sufficient financial information to prove the financial viability of the home The registered person in the absence of a registered manager must ensure that appropriate supervision of all grades of staff is carried out at least 6 times per year and formal records kept. The registered person must ensure that all steps are taken to ensure the health and safety requirements and safe working practices are maintained within the home at all times as listed in NMS 38 and that all staff receive appropriate training in all aspects of health and safety issues.. 28/02/06 30/01/06 30/01/06 30/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Laburnum Lodge DS0000015120.V263295.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB1 5XE 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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