Inspection on 12/06/06 for Langdale Lodge

This inspection was carried out on 12th June 2006.

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

Langdale Lodge 11/06/07

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Byars Care Home

St Marys Nursing Home

Bramble Lodge

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Thornham Grove

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London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Selhurst Lodge Selhurst Road Newbold Chesterfield Derbyshire S41 7HR Lead Inspector Rose Veale Unannounced Inspection 12 June 2006 10:00 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 Selhurst Lodge DS0000067637.V294081.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. Selhurst Lodge DS0000067637.V294081.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Selhurst Lodge Address Selhurst Road Newbold Chesterfield Derbyshire S41 7HR 0116 2246223 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) Miss Neemat Kassam Mrs Yasmin Nazir Kassam Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places Selhurst Lodge DS0000067637.V294081.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14/12/2005 Brief Description of the Service: Selhurst Lodge is located in a quiet residential area of Chesterfield, approximately a mile from the town centre. Personal care and accommodation is provided for up to 23 residents aged 65 years or over. The home is modern and purpose built with accommodation and communal areas on two floors. There is a mature garden accessible to residents. Selhurst Lodge DS0000067637.V294081.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over 6 hours. There were 23 residents accommodated on the day of the inspection, including 5 residents for short-term care. Residents and staff were spoken with during the inspection. Observations were made of the care provided. A tour of the building was carried out. Records were examined, including care records, medication and health and safety records. The home had recently changed ownership and the new owner was available and helpful during the inspection. What the service does well: What has improved since the last inspection? What they could do better: Residents needed access to a Statement of Purpose and Service User Guide to ensure they were well informed about the home. Assessment of residents’ needs and care planning needed further development to ensure residents’ needs were fully met. Staffing levels needed urgent action to ensure that residents were safe at all times and their needs properly met. Selhurst Lodge DS0000067637.V294081.R01.S.doc Version 5.1 Page 6 The development of systems and procedures - such as protection of vulnerable adults, safe handling of medication and quality assurance - was needed to ensure residents’ safety and welfare. Immediate Requirements were made at this inspection for the provider to address urgently the issues of insufficient staffing levels, risk assessment, fire safety, and the safe handling of medication. 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. Selhurst Lodge DS0000067637.V294081.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 Selhurst Lodge DS0000067637.V294081.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, 3 and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The assessment process was generally adequate to check that residents’ needs could be met by the home. However, the lack of thoroughness and consistency meant that residents’ needs were not always fully met and staff did not have all the information they required. EVIDENCE: There was no Statement of Purpose available. The home had very recently changed ownership and the new owner said the Statement of Purpose was being reviewed and updated. The care records of 4 residents were examined. The records included assessment information obtained before and following admission of the resident. The assessment information was of varying standards, two of the records seen had only brief details obtained prior to admission. The care plan and / or the community care assessment from the care manager was included in the records seen. It was found that there was very little information Selhurst Lodge DS0000067637.V294081.R01.S.doc Version 5.1 Page 9 available for one resident admitted the week prior to the inspection for shortterm care. The home’s new owner contacted the resident’s care manager during the inspection and the relevant information was faxed to the home. Standard 6 does not apply to this home. Selhurst Lodge DS0000067637.V294081.R01.S.doc Version 5.1 Page 10 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, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans were not detailed or comprehensive enough to ensure that residents’ needs were properly met and the medication system did not fully protect residents. EVIDENCE: All the records seen included individual care plans. The care plans did not include all the assessed needs of residents, or other needs referred to in daily records, and did not include sufficient detail of the action needed by staff to meet residents’ needs. For example, one care plan did not include the nutritional needs of the resident, one did not include the resident’s mental health needs even though the daily records noted treatment for depression, and one care plan only included the resident’s mobility needs. There were no routine weight records. Residents spoken with said their needs were met at the home, one resident commenting “I’m well looked after”. Staff spoken with were knowledgeable about the care needs and personal preferences of permanent residents, but not so sure about the needs of some of the residents in the home for short-term care. Selhurst Lodge DS0000067637.V294081.R01.S.doc Version 5.1 Page 11 There were records of the input of GPs and District Nurses. It was clear from the records that residents were referred promptly to the GP or to other services as required. For example, a resident was reported as feeling unwell with a troublesome cough and was seen by the GP the following day. Care plans and assessments had been reviewed regularly up to around March / April 2006, shortly before the new owners took over. Records and systems in the home were in the process of being reorganised by the new owner. There was evidence of residents’ privacy and dignity being supported. Residents spoken with said staff were “kind” and “patient”. Residents said that they were able to see visitors and their GP in private if they wished. Staff were observed to be respectful in their approach to residents and were observed to knock on doors before entering. Two of the care plans seen noted the resident’s preferences with regard to daily routines. One of the care plans showed that the resident was supported to maintain their independence where possible, for example, by taking care of medication, and bathing independently. Medication was stored in the hairdressing room, as reported at previous inspections. Staff spoken with said the room was not used for hairdressing. Some medication was still stored inappropriately in a filing cabinet in the office, as at previous inspections. The new owner said that a wall mounted drug storage cabinet had been ordered to address this problem. The Medication Administration Records, (MARs), were seen and appeared to be correctly completed. All except one of the MARs had a photograph of the resident. There were no records of medication received into the home. Records of medication disposed of were satisfactory. There was no policy regarding the safe handling, storage, administration, receipt and disposal of medication in the home. This was a requirement at previous inspections and an Immediate Requirement was made at this inspection for this to be addressed urgently. Staff spoken with said that all senior care assistants responsible for dealing with medication had received appropriate training. A report from the visiting pharmacist dated 09/02/06 indicated that all staff had the required training. Staff training records were not available at this inspection and so it was not possible to check. There was a requirement at the last inspection that there must be a risk assessment in place for a resident who was known to covertly store medication. This requirement had not been met and an Immediate Requirement was made at this inspection to urgently address this issue. Selhurst Lodge DS0000067637.V294081.R01.S.doc Version 5.1 Page 12 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): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Meals were of a good standard and were enjoyed by residents in pleasant surroundings. The activities programme lacked resources and did not meet the needs of all residents. EVIDENCE: Residents spoken with said there were some activities in the home, such as games and bingo. Two residents said they would like more activities and trips out. Staff spoken with said they tried to offer activities to residents, but this was not always possible because of low staffing levels, particularly at weekends, (see the Staffing section of this report). Residents spoken with said they could get up and go to bed when they wanted to. Residents said they were able to see their visitors in private if they wished and that their visitors were made welcome. Some residents chose to stay in their bedrooms and staff respected this choice. Residents spoken with were pleased with the meals offered and said they were given a choice if they did not want what was on the menu. One resident in the home for short-term care said they had particularly enjoyed the meals. The menus had been reviewed since the new owners took over and appeared Selhurst Lodge DS0000067637.V294081.R01.S.doc Version 5.1 Page 13 varied and well balanced. Fresh fruit and vegetables were offered every day. The dining room on the ground floor was pleasant and welcoming with tables attractively laid at lunchtime. The lunch served on the day of the inspection appeared appetising. Selhurst Lodge DS0000067637.V294081.R01.S.doc Version 5.1 Page 14 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 and 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The complaints procedure was not fully accessible to residents and there were no systems in place to protect residents from abuse. EVIDENCE: The home’s complaints procedure was displayed near the entrance area. The procedure did not include a timescale for response to complaints. Residents had not received a Service User’s Guide, which would include a copy of the complaints procedure. The new owner said that this was being developed. The home did not have a policy for the protection of vulnerable adults and staff spoken with said they had not had training in this area. Two of the staff spoken with were aware of the procedures to follow if abuse was suspected. Selhurst Lodge DS0000067637.V294081.R01.S.doc Version 5.1 Page 15 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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents lived in a pleasant, clean, comfortable and generally well maintained home. EVIDENCE: The home is modern and purpose built and appeared generally well maintained. Communal areas were pleasant, well decorated and comfortably furnished. It was noted that, as at previous inspections, most residents were seated in the ground floor lounge and this appeared over full. Some residents were seated in the entrance area to the home. There was a lounge on the first floor but staff said most residents preferred to use the ground floor lounge and that staffing levels did not always allow for safe use of lounges on two floors, (see Staffing section of this report). The bedrooms seen were bright, pleasant and personalised with residents’ own belongings. The home was clean throughout and free from offensive odours. Residents spoken with said they were pleased with their rooms and that the home was always clean. Selhurst Lodge DS0000067637.V294081.R01.S.doc Version 5.1 Page 16 The laundry was suitably equipped. Staff spoken with said they had not had training in the control of infection. Staff were observed to use disposable plastic aprons when assisting with personal care and to wear tabards for serving meals. It was noted that the ground floor bathroom was not used as there was no bath hoist and staff said that there were no residents who could safely step in and out of the bath. A ground floor shower was also not used as it was not easily accessible to residents. The bathing / showering facilities should be reviewed by the new owners with a view to providing a more accessible bath and shower on the ground floor. There was an accessible shower provided on the first floor. The first floor bathroom had a fixed bath hoist and was said to be used by most residents. The side panel of the bath was damaged and needed repair or replacing. Selhurst Lodge DS0000067637.V294081.R01.S.doc Version 5.1 Page 17 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, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels were not sufficient to meet residents’ needs or to ensure the safety of residents. EVIDENCE: Residents spoken with said that there were enough staff on duty to meet their needs for personal care. Residents said they would like more activities and trips out and staff spoken with said that staffing levels did not allow for this. It was noted that residents were sometimes unable to sit out in the garden as there were insufficient staff to provide adequate supervision. The staff rotas for the home were seen and showed that staffing levels were usually 3 care assistants working from 7am to 2pm, 2 from 2pm to 9pm and 2 from 9pm to 7am. At weekends there were 2 care assistants working each shift. The staffing levels were not sufficient to meet residents’ needs. The Residential Forum guidelines for care homes indicated that there should be 3 staff on duty during the day and 2 at night for the numbers and dependency level of residents in the home. It was noted that the new owners had started to provide an additional care assistant from 4pm to 8pm where possible. The new owner said that recruitment of new staff was in progress and that the aim was to provide staffing levels of a minimum of 3 staff during the day. On the day of the inspection there were several telephone enquiries in response to an advertisement for care assistants. The new owner also said that it was Selhurst Lodge DS0000067637.V294081.R01.S.doc Version 5.1 Page 18 intended to employ another domestic assistant, and a cook to cover two days per week. An Immediate Requirement was made at this inspection that sufficient staffing must be provided to ensure the safety and welfare of residents. Staff personal records and staff training records were not available at this inspection as the key to the filing cabinet could not be found. These records will be checked on the next visit to the home. Selhurst Lodge DS0000067637.V294081.R01.S.doc Version 5.1 Page 19 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, 33, 35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Satisfactory arrangements were in place to ensure the home was properly managed. There was no system in place to ensure the home was run in the best interests of residents. Residents and staff were put at risk by breaches in the fire safety procedures. EVIDENCE: The new owner had made temporary management arrangements for the home and said it was intended to appoint a permanent manager within the next 3 – 4 months. Staff spoken with said they had confidence in the new owner to make improvements in the home. There was no formal quality assurance system in the home. The new owner said this was being developed. Selhurst Lodge DS0000067637.V294081.R01.S.doc Version 5.1 Page 20 The fire log book was examined had showed that weekly testing of fire alarms had not been kept up to date and also that fire drills had not taken place every 6 months as recommended by the fire service. An Immediate Requirement was made at this inspection to urgently address this issue. Selhurst Lodge DS0000067637.V294081.R01.S.doc Version 5.1 Page 21 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 1 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 3 X X X X X X 3 STAFFING Standard No Score 27 1 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X X X X 2 Selhurst Lodge DS0000067637.V294081.R01.S.doc Version 5.1 Page 22 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4(1)(2) Requirement There must be a Statement of Purpose available for inspection by any resident or their representative. There must be a Service User Guide available to each resident. Accommodation must not be offered to residents until a suitably qualified or trained person has assessed their needs and the provider has obtained a copy of the assessment. Each resident must have a care plan that includes all their assessed needs. All medication must be stored in a secure place used only for the storage of medication. Original timescale 30/09/05 There must be procedures in place for the protection of vulnerable adults. Staff must have training in the protection of vulnerable adults. The side panel to the bath in the first floor bathroom must be repaired or replaced. Staff at the home must receive appropriate training for the work DS0000067637.V294081.R01.S.doc Timescale for action 30/06/06 2. 3. OP1 OP3 5(1)(2) 14(1) 14/07/06 30/06/06 4. 5. OP7 OP9 15(1) 13(2) 14/07/06 31/07/06 6. 7. 8. 9. OP18 OP18 OP19 OP30 13(6) 13(6) 23(2)(c) 18(1)(c) 14/07/06 30/09/06 14/07/06 30/09/06 Selhurst Lodge Version 5.1 Page 23 10. OP33 24(1)(2) (3) 26(1)(3) (4)(5) 11. OP33 12 13 OP36 OP38 18(2) 13(3) 14 15 OP38 OP38 13(4) 13(4)(a) (b)(c) they are to perform. Original timescale 31/03/06 There must be a system in place to review the quality of care provided at the home. Original timescale 31/05/06 The registered provider must make an unannounced monthly inspection visit to the home and prepare a report which is to be supplied to CSCI. There must be arrangements in place for the supervision of staff. Original timescale 30/04/06 Staff must receive training in infection control and food hygiene. Original timescale 30/04/06 Staff must receive training in first aid. Original timescale 30/04/06 The home must have health and safety procedures and risk assessments in place for all hazards. Original timescale 31/03/06 30/09/06 31/07/06 30/09/06 30/09/06 30/09/06 30/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard OP12 OP19 OP31 OP36 Good Practice Recommendations A more structured programme of activities should be developed in consultation with residents. Ground floor bath and shower facilities with easier access for residents should be considered. Permanent management arrangements should be in place within 3 – 4 months of the change of ownership. Staff should have supervision sessions 6 times per year. Selhurst Lodge DS0000067637.V294081.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Selhurst Lodge DS0000067637.V294081.R01.S.doc Version 5.1 Page 25 - 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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