Inspection on 04/11/05 for Lashbrook House

This inspection was carried out on 4th November 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Lashbrook House 01/12/06

Lashbrook House 24/02/06

Lashbrook House 15/03/05

Lashbrook House 16/09/04

Lashbrook House 10/12/03

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Lashbrook House Mill Road Shiplake Henley-on-Thames Oxfordshire RG9 3LP Lead Inspector Annette Miller Unannounced Inspection 12.00p 4 November 2005 th 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 Lashbrook House DS0000027161.V260418.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Lashbrook House DS0000027161.V260418.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Lashbrook House Address Mill Road Shiplake Henley-on-Thames Oxfordshire RG9 3LP 0118 9401770 0118 9404342 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) Majestic Number One Limited Suresh Gogna Care Home 46 Category(ies) of Dementia - over 65 years of age (14), Old age, registration, with number not falling within any other category (46) of places Lashbrook House DS0000027161.V260418.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Maximum of 30 persons with nursing needs. On admission persons should be aged 60 years and over. Date of last inspection 15th March 2005 Brief Description of the Service: Lashbrook House is registered to provide residential and nursing care for up to 46 service users aged 60 years and over. Registered nurses are on duty 24 hours a day. The home is situated in an attractive part of Oxfordshire near the river Thames and there is a railway station in the nearby village of Shiplake, as well as a post office and shop. The home has two floors. There are 30 single bedrooms and one double room on the ground floor, as well as two lounges, a dining room and a reception area. The first floor has 12 single bedrooms, one double room and also a lounge/diner. Most rooms have en-suite facilities of toilets and washbasins. The five bedrooms without these facilities are provided with washbasins. Activities are arranged in the home on weekdays, as well as trips out in the home’s minibus. The home is set in extensive grounds with lovely views across open countryside. Lashbrook House DS0000027161.V260418.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out by one inspector from 12.00pm to 4.00pm. The inspector spoke to residents and staff to obtain their views of the home. A tour of the building and inspection of documents also took place. Mrs Suresh Gogna (Registered Manager) was present during the inspection. The Commission for Social Care Inspection (CSCI) received three comment cards from care managers and their responses were good. Two care managers commented that they were always kept informed of changes to clients’ care. One care manager sent a letter setting out why she thought the home was good. She made comments such as, “I have found the care provided at the home to be of an extremely high standard”, and “Communication is absolutely first class from both Mrs Gogna and her staff”. Four GPs returned comment cards and positive comments were made. One GP said, “Very well run, caring home”. What the service does well: What has improved since the last inspection? What they could do better: The registered person must arrange for written information to be produced that explains to residents how they receive NHS money for nursing care. Please contact the provider for advice of actions taken in response to this Lashbrook House DS0000027161.V260418.R01.S.doc Version 5.0 Page 6 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Lashbrook House DS0000027161.V260418.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lashbrook House DS0000027161.V260418.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3 The home’s Statement of Purpose and Service User Guide provide residents and prospective residents with details of the services provided, enabling an informed decision about admission to the home. The company does not currently provide written information to residents about how NHS money for nursing care is paid. Without this there is no assurance that residents are fully informed regarding this matter. EVIDENCE: Lashbrook House has a Statement of Purpose and a Service User Guide that contain comprehensive information about all aspects of the home. New residents are given a copy of the Service User Guide as part of the admission pack and copies are also available in the home. Residents receive a contract of residence that sets out in detail what they can expect from the home and what is included in the fee. Lashbrook House DS0000027161.V260418.R01.S.doc Version 5.0 Page 9 The manager assesses all prospective residents to determine whether or not the home meets the person’s needs. The home’s pre-admission assessment form is clear and comprehensive covering all the necessary areas of need and forming the basis of a resident’s care plan. NHS nurses assess residents after admission to determine how much nursing care is needed, and the level of NHS funding to be paid. The manager said she informed residents verbally of this procedure and provided an explanatory booklet about NHS funded nursing care in nursing homes, published by the Department of Health. The money paid by the NHS for nursing care is paid directly to the company and it is the responsibility of the company to inform residents in writing about how the NHS contribution is paid to them. This information is not currently provided. Requirement. Lashbrook House DS0000027161.V260418.R01.S.doc Version 5.0 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 and 8. The standard of care planning is good ensuring that residents’ health and social care needs are well met. EVIDENCE: Individual plans of care are available and the two plans selected for inspection showed that all aspects of health, personal and social care needs were identified and planned for. Significant events were recorded and daily care records kept. Skin condition is assessed on admission to determine the level of risk of developing pressure sores. The decision to provide pressure-relieving mattresses and cushions is based on the outcome of assessment. Training regarding pressure damage and wound care is provided. Four registered nurses attended wound care training in September 2005 and a carer attended pressure damage training in May 2005. A GP who was in the home during the inspection said he thought the standard of care was good. This view was confirmed by the responses made in the comment cards returned to CSCI by health and social care professionals. Lashbrook House DS0000027161.V260418.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 and 15. Social and recreational activities are particularly good in this home and, as a result, residents’ lives are enriched. Links with the community are also good, providing residents with regular contact with local people. EVIDENCE: Residents and staff were preparing for a bonfire night party to be held during the evening. The manager said that 15 residents had indicated they would be attending, together with friends and relatives. A resident said she was looking forward to the event and was pleased her daughter and grandchildren had been invited. Mulled wine, hot food and a selection of desserts were being prepared. During the afternoon six residents were sitting around a table in the dining room with two members of staff playing cards. The interaction between staff and residents was good and the atmosphere was lively and friendly. An activity organiser works 25 hours over three days. Two part-time members of staff were being trained to carry out hostess duties which included helping with activities. They were replacing the full-time hostess who was leaving because she was moving away from the area. Lashbrook House DS0000027161.V260418.R01.S.doc Version 5.0 Page 12 The lunchtime meal looked and smelled appetising and three residents spoken to during lunch said they were enjoying their meal. A choice of main course is provided daily and there is always a selection of desserts. Wine and soft drinks are served at lunchtime. Several of the residents needed assistance from staff to eat and this was provided in an unhurried way by staff who sat next to them to give one-to-one help. A heated food cabinet for the ground floor has been purchased to keep food hot until assistance for people who need help is available. Lashbrook House DS0000027161.V260418.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 The complaints policy adequately sets out the procedure for making a complaint, except that it states that complainants who remain dissatisfied can send their complaint to the Health Service Ombudsman. This Ombudsman only deals with complaints about NHS employees and therefore complaints could be misdirected. EVIDENCE: The Lashbrook House complaints policy is included in the Service User Guide and copies are also available in the home. The address and telephone number of the Commission for Social Care Inspection (CSCI) is provided for any complainant who might wish to contact CSCI directly. No complaints have been received since the last inspection by the home or CSCI. The complaints policy states that complainants can refer a complaint to the Health Service Ombudsman if a complainant is dissatisfied with the way in which the company or CSCI deals with their complaint. This is incorrect because the Health Service Ombudsman only deals with complaints about NHS employees. The company is advised to revise its policy with regard to this information. Recommendation. Lashbrook House DS0000027161.V260418.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 26. The home’s environment and facilities provide residents with a homely and safe place to live. EVIDENCE: Aids and equipment to promote independence are provided, such as grab rails in bathrooms and toilets, and handrails in corridors. A lift to the first floor is available and specialist engineers provide regular maintenance. Referrals to specialist services, such as physiotherapy, occupational therapy and the Oxfordshire wheelchair service, are made depending on need. Call bells with an emergency alarm sound are provided. Cleanliness throughout the home was particularly good and there were no unpleasant smells. Staff hand washing facilities are prominently sited throughout the home. Infection control training is provided for all staff members during induction and subsequent updates. Lashbrook House DS0000027161.V260418.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 and 28. Staff morale is high resulting in an enthusiastic workforce that works positively with residents to improve their quality of life. EVIDENCE: The home was full with 46 residents (one bed was being kept for a resident who was in hospital). Two registered nurses and seven carers were on duty and, from the observations made by the inspector and discussions held with staff and residents, this level of staffing seemed adequate for the present residents’ needs. A hostess/activity member of staff was also on duty and was training two members of staff to take over from her when she leaves. She said she would be sad to leave as she had enjoyed the work very much but was moving away from the area. Administration, catering, domestic and maintenance staff were also on duty ensuring the home’s high standards were maintained in all areas. Three carers have completed NVQ training and four carers have a qualification that is equivalent to at least NVQ Level 2. This equates to 39 of care staff with NVQ training. One member of staff has recently started NVQ training. To achieve a fully met score for Standard 28 the percentage of carers with an NVQ qualification must reach 50 . Lashbrook House DS0000027161.V260418.R01.S.doc Version 5.0 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 and 32 The manager is supported well by the company and her senior staff in providing clear leadership throughout the home, with all staff demonstrating an awareness of their roles and responsibilities. EVIDENCE: Mrs Suresh Gogna is an effective manager and has the support of her staff team. Two registered nurses spoke individually to the inspector and they each praised Mrs Gogna for the support she provided. They confirmed that they were able to see her at short notice to discuss any work or personal matter, and that they were very happy working in the home. Mrs Gogna is a registered nurse and regularly updates her nursing knowledge. She is an NVQ assessor and has recently completed a mentorship programme that has provided her with the knowledge and skills required by the Nursing and Midwifery Council (NMC) to mentor overseas nurses during a training programme leading to registration with the NMC. Mrs Gogna has also successfully completed the Registered Manager’s Award. Lashbrook House DS0000027161.V260418.R01.S.doc Version 5.0 Page 17 Extremely good comments were made about the way the home was managed by the health and social care professionals who returned comment cards to CSCI. Mrs Gogna regularly meets with residents to discuss their care and it was clear that she had a good understanding and awareness of their needs. Lashbrook House DS0000027161.V260418.R01.S.doc Version 5.0 Page 18 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 2 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X X X X 3 X X X 3 STAFFING Standard No Score 27 3 28 2 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X X X X X Lashbrook House DS0000027161.V260418.R01.S.doc Version 5.0 Page 19 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 OP1 Regulation 5A Requirement The registered person must arrange for written information to be produced that explains to residents how they receive NHS money for nursing care. Timescale for action 31/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP16 Good Practice Recommendations The registered person should review the home’s complaints procedure to ensure that the information provided is up-to-date and accurate. Lashbrook House DS0000027161.V260418.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU 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 Lashbrook House DS0000027161.V260418.R01.S.doc Version 5.0 Page 21 - 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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