Inspection on 03/07/07 for Laburnum Lodge

This inspection was carried out on 3rd July 2007.

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 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

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 03/01/07

Laburnum Lodge 30/05/06

Laburnum Lodge 20/12/05

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

Similar services:

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 Neil Fernando Key Unannounced Inspection 3rd July 2007 10:15 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.V339550.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Laburnum Lodge DS0000015120.V339550.R01.S.doc Version 5.2 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 860845 Dr A Hassaan Mrs S Hassaan Mrs Julie Dawn Cousins Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places Laburnum Lodge DS0000015120.V339550.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd January 2007 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 to 22 older people. The upper floor is accessed via stairs or a stair lift. A garden is available to the rear of the building. The home is situated in the centre of the village of Littleport and is close to shops, cafes, pubs and local amenities. A copy of the most recent inspection report is available in the entrance way to the home. The weekly charge is £340. Laburnum Lodge DS0000015120.V339550.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place on 3 July 2007. The last inspection was unannounced and took place on 3 January 2007. The inspection was carried out by two inspectors and lasted for about 3.5 hours, starting at 10:15 am. 7 residents, 4 members of staff including the manager were spoken to, in order to seek their views regarding the quality of services offered to residents at this home. The visit also provided an opportunity to observe staff care practices; medication administration was checked and a range of documents was viewed. A tour of the premises was also undertaken. This report is also informed by any information received by the CSCI about Laburnum Lodge or any significant events that have taken place since the previous inspection visit in January 2007. The CSCI has received 7 completed comment cards from residents and feedback from them is positive. Six additional bedrooms have been registered since the last inspection. At the time of the visit there were 21 people accommodated. Overall, residents spoken with were positive and they expressed a high level of satisfaction with respect to the services offered. Comments from individuals on the day of inspection included “I am very happy here”; staff treat me “with great respect”; “I like everything I have seen so far, very homely and staff are friendly” reported a new resident. What the service does well: Laburnham Lodge provides a comfortable environment in which service users feel secure and at home. Residents spoken with reported that staff were friendly and caring, and expressed confidence in their skills and knowledge. The visiting GP also praised the standards of care in the home and the kindness and dedication of the staff team, including the manager. The standard of care seen was good: staff members treat service users with respect and courtesy. During the inspection, the main meal was being served and staff members including the cook were present in the dining room to support service users. All residents spoken to said the food provided was good and plentiful. The residents were well presented physically and appeared well cared for. A hairdresser visits regularly and residents appeared to value this facility very much. Contacts with family and friends are encouraged and well supported. Laburnum Lodge DS0000015120.V339550.R01.S.doc Version 5.2 Page 6 The staff members on duty appeared very committed and positive, and felt well supported. They were enthusiastic about their work, and said that they have a good level of training to enable them meet the needs of the resident group. NVQ training in care for staff is being given a high profile. What has improved since the last inspection? What they could do better: There are 6 requirements arising from this report, that need addressing. Whilst staff members have received training on the safe use of medicines, the prescribing and administration of medicines indicated some real concerns. With this in mind, the administration, recording and control of medication must be reviewed and improved, in order to protect residents. All complaints, no matter how minor, must be recorded, investigated and action taken to resolve them so that residents can be assured that their concerns are taken seriously This inspection has identified a number of hazards around the home, under standards 19-26 of this report. These must be addressed to ensure residents’ safety. Residents must be provided with keys to lock their bedroom doors. This is vital to ensure their privacy and also the safety of their belongings. This was raised as part of the registration of six new bedrooms. The provider has failed to address this issue. Laburnum Lodge DS0000015120.V339550.R01.S.doc Version 5.2 Page 7 Two bedrooms have an adjoining door into the next bedroom. These doors are not fire resistant or sound proof, and are potentially dangerous and confusing for residents. They must be removed and sealed over. This was raised as part of the registration of six new bedrooms. The provider has failed to address this issue. Staff personnel files must contain a photograph of the staff member to meet with requirements. The provider, Mr Hassaan, must visit the home at least monthly and prepare a report based on speaking with service users and staff, and also the condition of the environment. This is vital if standards are to be monitored and maintained at the home. 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. The summary of this inspection report can be made available in other formats on request. Laburnum Lodge DS0000015120.V339550.R01.S.doc Version 5.2 Page 8 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.V339550.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,5 Quality in this outcome area is good. Information is available about the home to help residents decide if it is where they want to live. Residents’ needs are assessed to ensure that they can be fully met at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a Statement of Purpose that gives good information about the home’s facilities and services. This document could be further improved if it was in a format suitable for its readers such as large print or audio. The manager or a senior member of staff visits all prospective residents to complete an assessment of their needs, and encourages them, where possible, to come and spend a day at the home to sample life there. Two residents spoken to, confirmed that they had visited the home before moving in and complimented the manager for taking time to show them around and explain how the home operates. Pre-admission assessments were viewed on the files checked. Each resident is issued a contract that, although basic, does state the terms and conditions of their stay at the home. Laburnum Lodge DS0000015120.V339550.R01.S.doc Version 5.2 Page 10 Laburnum Lodge DS0000015120.V339550.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. Care plans are detailed and ensure staff have the information to care for residents consistently. However, medication practices are poor and do not adequately protect residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three residents’ care plans were checked. The information they contained was detailed and up to date. Residents’ needs in a number of areas including personal hygiene, dressing, mobility, communication and eating were clearly identified and there was additional information about their life history. The care plans had been signed by those residents who were able, and had been reviewed monthly. Residents are weighed monthly and their food intake is monitored closely. They have access to a range of health care professionals including GPs, district nurses and a chiropodist. The inspector spoke with a GP who was visiting a resident on the day of inspection. He reported that the quality of care received by his patients was high, and staff showed a good understanding of their needs. Laburnum Lodge DS0000015120.V339550.R01.S.doc Version 5.2 Page 12 Residents reported that staff treated them well and interactions between staff and residents were observed to be appropriate and respectful. Training on the safe use of medicines has been provided for staff, however records of the prescribing and administration of medicines showed some worrying deficiencies: • • • • • There were a number of gaps in the administration records giving no indication of whether medicines were administered or not Some tablets had been signed as having been given to a resident but in fact were still in the blister pack The amount of tablets actually held a the home did not tally with the amount recorded A number of residents’ tablets had not been recorded as having been received into the home Hand written additions to the MAR sheets were not signed or dated. Laburnum Lodge DS0000015120.V339550.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15 Quality in this outcome area is good. Activities provide residents with entertainment and stimulation. Residents maintain good links with their families and mealtimes are enjoyable. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There are regular activities in the home for residents to enjoy such as armchair aerobics, pamper sessions, bingo, skittles and hangman. There are regular visits from a variety of local clergy and the Sally Army. Residents told the inspector how much they had enjoyed a Strawberry Tea at the local village hall, and were looking forward to a trip to a butterfly park. One resident helps fold the home’s laundry every day and clearly enjoys being able to help in this way. Friends are family are made to feel very welcome at the home and many were seen visiting on the day of inspection. One resident told the inspector ‘they always make my visitors a cup of tea’. Residents reported the food to be good and that there was always a choice of what to eat; “Food is nice and plentiful”, said two resodents. One resident reported that she hadn’t been eating properly before she moved into the home Laburnum Lodge DS0000015120.V339550.R01.S.doc Version 5.2 Page 14 but was now putting on weight. All of the five residents spoken to were aware of what was on the menu, including deserts. Lunch on the day of inspection consisted of salmon and chips or salad, followed by pancakes or bananas and custard. The food looked plentiful and nutritious and lunch was a relaxed a sociable event, with attentive staff present. Baskets of fruit and crisps were available on tables for residents to help themselves, and were proving very popular. This practice is to be commended. Laburnum Lodge DS0000015120.V339550.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is adequate. Residents spoken to felt able to make a complaint. There is a need however, to ensure that all complaints, no matter how minor are recorded and investigated, and action taken as required so that residents know their concerns are taken seriously. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has its own complaints procedure, details of which are in its Statement of Procedure and on display in the entrance hallway. Residents have a copy of the complaints procedure in their bedrooms and it was reported that their relatives are informed how to make a complaint. Some of the residents spoken to were not fully aware of the home’s complaints procedure but identified the manager as someone they could speak to if they were unhappy about their care. However, it was of concern to note that two residents had complained about not being able to lock their bedrooms doors to stop other residents wandering in. These concerns had not been formally recorded and it was not clear what action, if any, had been undertaken to address them. The home’s procedures on adult protection are satisfactory. The “Whistle Blowing” policy is also available to the staff team. Staff members, bar two, have received training in protecting vulnerable adults so that they are aware of common signs and symptoms and appropriate reporting procedures. An element of this is included for those members who have completed their NVQ assessment. The manager reported that this training is to be made accessible to the two members. Laburnum Lodge DS0000015120.V339550.R01.S.doc Version 5.2 Page 16 Evidence of POVA First and CRB checks was available on the staff files viewed. Laburnum Lodge DS0000015120.V339550.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,26 Quality in this outcome area is adequate. Residents live in a homely and comfortable environment and have access to a range of communal spaces. However, some maintenance items need to be addressed to protect residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The premises were observed to be clean, bright and well maintained, with good quality furnishing and fittings in place. There is a very homely feel throughout, helped by the presence of a cat. Residents have access to two lounges and a dining room area. However, there is no separate area for staff to change their clothes, have their breaks in, or hold meetings in. The inspector had to use a residents’ bedroom in order to interview staff privately. The manager’s office is very small and cramped and does not provide enough storage for all required paperwork, or for individual meetings with staff members. Laburnum Lodge DS0000015120.V339550.R01.S.doc Version 5.2 Page 18 The following items were noted and must be addressed: • • • • • • • Residents in the new extension are unable to lock their bedroom doors. This compromises their privacy and security. Two bedrooms have adjoining door into the neighbouring bedrooms. These doors are not fire resistant or sound proof, and are potentially dangerous and confusing for residents. Tiling in the shower room is coming away from the wall. This is a hazard for residents. Paintwork on external windows and doorframes is peeling, giving the home a shabby and neglected feel Room 19 smelled strongly of stale urine A number of wheelchairs were stored precariously in the residents’ dining room There is poor ventilation in the laundry room. The home has been subject to additional visits from the environmental health officer due to concerns about the lack of separate staff facilities and some kitchen hygiene practices. A previous rat infestation at the home has now been dealt with. Laburnum Lodge DS0000015120.V339550.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. Staffing numbers are appropriate to the needs of the resident group. Staff training good and ensures residents receive their care from skilled staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staffing arrangements have been reviewed and there are now an extra care staff available on each day and night shift. In terms of numbers and skill mix, the staffing arrangements were appropriate to ensure that the needs of the service users could be met. Information gained from residents and staff including the manager, confirm that they consider the staffing levels to be appropriate; also, all seven residents spoken with were very positive about the quality of assistance they received. Training profiles for three staff members were viewed and these indicated that they have good opportunities for relevant training. All members of staff have completed their mandatory training. Eight care staff members have completed their NVQ Level 2 award and six are currently doing NVQ Level 3. The home follows the Organisation’s procedures for the recruitment and selection of staff members. Good evidence is available to indicate that the Manager has made a concerted effort to ensure that all new recruits are Laburnum Lodge DS0000015120.V339550.R01.S.doc Version 5.2 Page 20 subject to in depth checks, prior to them starting work. The personnel recruitment files for three staff including one recently appointed member were scrutinised. Minor improvement (for example a current photo) is required to reflect the documents stated in Schedule 2 and 4 of The Care Homes Regulations 2001. Laburnum Lodge DS0000015120.V339550.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 36 and 38 Quality in this outcome area is good. The home is well managed and run in the best interests of the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The management systems are transparent and service users and staff members confirmed that the manager is supportive. She is also regarded favourably by outside professionals, involved with the home. Teamwork is reported to be good and regular staff meetings are held. All staff members attend in daily handovers at the home. Observation of care practice during the visit also demonstrates that staff and residents enjoy a very good relationship. Staff receive regular supervision of their working practices and details of their supervision sessions are maintained. Staff confirmed that they receive Laburnum Lodge DS0000015120.V339550.R01.S.doc Version 5.2 Page 22 supervision at least once every two months and appeared to appreciate this very much. Health and safety training is provided on a rolling training programme and records show that health and safety checks had been carried out; these include fire safety equipment testing and servicing, and fire safety checks. Fire drills have been carried out within the required frequency. There is however a number of health and safety issues identified under standards 19-26 of this report, which require addressing. Laburnum Lodge DS0000015120.V339550.R01.S.doc Version 5.2 Page 23 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 3 x 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 2 1 2 x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x x 3 3 2 Laburnum Lodge DS0000015120.V339550.R01.S.doc Version 5.2 Page 24 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. 1. Standard OP9 Regulation 13 (2) & 17 (1) (a) Requirement The administration and recording of medication must be reviewed and improved, in order to protect residents. All complaints must be recorded and investigated so that residents know their concerns are taken seriously. Item numbers 1-7 noted under standards 19-26 of this report must be addressed so that residents live in a wellmaintained and safe environment. In particular residents must be able to lock their bedroom doors, and adjoining bedroom doors must be removed. Staff personnel files must contain a photograph of the staff member. A monthly report must be written by the provider on the conduct of the home and a copy of it sent to the CSCI. Timescale for action 31/07/07 2 OP16 22 (3) & (4) 13(2)(c) 31/07/07 3 OP19 01/09/07 4 OP29 19 (1) (b) & Sch. 2 (1) 26 31/07/07 5 OP37 01/08/07 Laburnum Lodge DS0000015120.V339550.R01.S.doc Version 5.2 Page 25 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.V339550.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Laburnum Lodge DS0000015120.V339550.R01.S.doc Version 5.2 Page 27 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!