CARE HOMES FOR OLDER PEOPLE
Lodge (The) Collier Row Lodge Lane Collier Row Romford Essex RM5 2HX Lead Inspector
Helen Fontaine Unannounced Inspection 3 October 2005 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 Lodge (The) Collier Row DS0000027862.V254050.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. Lodge (The) Collier Row DS0000027862.V254050.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Lodge (The) Collier Row Address Lodge Lane Collier Row Romford Essex RM5 2HX 01708 732293 01708 781122 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) Mr Ian George Nicoll Mrs Patricia Constance Nicoll Care Home 63 Category(ies) of Old age, not falling within any other category registration, with number (63) of places Lodge (The) Collier Row DS0000027862.V254050.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 17th February 2005 Brief Description of the Service: The Lodge is situated in Lodge Lane, which is close to Collier Row where local shops, cafes and restaurants can be found. There is easy access to local towns such as Romford and Ilford. The 249 bus stops directly outside the home. Train services are close by which go to London Central and the Home Counties. The accommodation comprises of single rooms, one double room provided for shared occupancy and all having en-suite toilet facilities. The communal areas consist of three well-furnished lounges on the ground floor with one lounge on the first floor. There are two spacious dining rooms to cater for the differing needs and choice of the residents. Residents are free to choose which dining room they would prefer. The home caters for residents over the age of 65 and provides a range of activities and services both internally and externally. The home was well decorated and welcoming. The home is one of three homes privately owned by the organisation and managed by the proprietor with the assistance of a deputy manager and experienced staff. Lodge (The) Collier Row DS0000027862.V254050.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection took place over 3 hours and was carried out as part of the yearly inspection programme. The previous unannounced inspection was on 17th February 2005, there were five requirements identified. The inspector did a tour of the building and a number of records were looked at. Seven residents, one visitor and two members of staff was spoken to, the Manager was not present for the first part of the inspection. What the service does well: What has improved since the last inspection? What they could do better:
It is of concern to the Commission that there are several requirements that are repeated in this inspection, some of which have been carried forward twice. (These are: pre-admission assessments, records of service user’s wishes upon their death, adult protection training, staffing levels and an NVQ qualification for the manager). The registered persons must ensure that these requirements are met within the new timescales stated, otherwise the Commission is likely to take enforcement action against them. There remains the concern about the assessment prior to admittance, which is still not being done. Staff spoken to during the inspection did not know the procedure for reporting alleged abuse, although there was evidence of adult protection training.
Lodge (The) Collier Row DS0000027862.V254050.R01.S.doc Version 5.0 Page 6 Staffing levels still remain an issue and the home have failed to send the Commission for Social Care Inspection a review of the action plan. There must be adequate numbers of care staff to meet the needs of the Service Users. Care plans need to be reviewed regularly and must record the Service Users wishes around death and dying. The home must make sure that opened food containers are labelled and dated. 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. Lodge (The) Collier Row DS0000027862.V254050.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 Lodge (The) Collier Row DS0000027862.V254050.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, 3 and 5 All prospective Service users are given information to make an informed choice about where they live. Assessments of Service Users moving into the home are not being done in full, putting the Service Users at risk of the home not meeting their needs. Service users their relatives and friends, have the opportunity to visit the home. EVIDENCE: The home does make sure that Service Users have the information they need, before they move into the home. During the inspection relatives of a prospective Service User were being shown around the home, as well as being given written information. Two Service Users said that they were neighbours and both having seen the home moved into the home together. The admission procedure is not adequate to guide staff on the actions to be taken to ensure that new residents needs are properly assessed and planned for. This failure could have serious repercussions for the health and welfare of the residents. Individual records are kept for each of the residents and inspection of the records for the most recent admission did not have a full assessment recorded for them. This situation has resulted in Service Users being admitted outside
Lodge (The) Collier Row DS0000027862.V254050.R01.S.doc Version 5.0 Page 9 of the homes registration and resulted in an Requirement at the last inspection. Although the home has made efforts to address this, the risk remains unless a full assessment is carried out. Lodge (The) Collier Row DS0000027862.V254050.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 11 Service Users health, personal and social care needs were not set out fully in the Care Plan. Residents are at risk of not having their health care needs met if the Care Plans are not fully completed. The Care Plan did not assure Service Users that at the time of their death their wishes would be met. EVIDENCE: Individual plans of care of the newest Resident were looked at along with a number of Service Users, who have been at the home for sometime. The Care Plans were basic, they were not dated and there was no indication that the Service User had been involved. Service Users files looked at did not mention the wishes of the Residents around the issues of death and dying. Lodge (The) Collier Row DS0000027862.V254050.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): 13, 14 and 15 Service Users maintain contact with family, friends and the local community as they wish. Staff help Service Users to exercise choice and control over their lives. Service Users also receive a wholesome, appealing and balanced diet in very pleasing surroundings. EVIDENCE: A number of people living in the home were spoken to and everyone commented on the food and said how much they looked forward to meal times. The dining rooms were of a very high standard and the Service Users commented on this. During the inspection a number of visitors were seen to come from the home, along with other professionals. Service Users were also observed to be coming and going from the home, accessing the local community as they wished. It was observed during the Inspection, staff supporting Service Users exercise choice and control over their lives. One Resident spoken to liked to remain in their room and staff never enter a room their without consent. Lodge (The) Collier Row DS0000027862.V254050.R01.S.doc Version 5.0 Page 12 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Service Users and their relatives and friends are confident that their complaints and comments will be listened to, taken seriously and acted upon. Staff at the home are not clear on the procedures on abuse and are not therefore protecting Service Users. EVIDENCE: Service Users and the visitor spoken to did feel very confident that their complaints and comments are listened to and would be taken seriously and dealt with. Staff spoken to also felt that all complaints would be listened to and dealt with, however the staff did not know about the procedure for dealing with abuse. Staff said that they would report any suspected abuse to the senior, but did not know they could contact the Commission for Social Care Inspection or about the Local Authority procedures. Lodge (The) Collier Row DS0000027862.V254050.R01.S.doc Version 5.0 Page 13 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 24 and 26 Service Users live in a safe, well-maintained environment and have access to safe, comfortable indoor and outdoor facilities. There are sufficient and suitable lavatories and washing facilities. Service Users have comfortable bedrooms with their own possessions around them. The home is very clean, pleasant and hygienic. EVIDENCE: During the inspection a tour of the home was made and it was observed that the home is very well maintained to a high standard. There are very comfortable indoor and some really nice outdoor facilities. Each of the bedrooms had en-suite facilities and in addition to these, there were bathrooms and toilets off the corridors. During the inspection a number of Service Users were spoken to in their rooms, each room was personalized with their own possessions. The whole environment of the home is clean, pleasant and hygienic, being maintained at a very high standard. Lodge (The) Collier Row DS0000027862.V254050.R01.S.doc Version 5.0 Page 14 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 and 30 Service Users needs are not being met, as the numbers and skills mix of the staff are not adequate. Service Users are protected by the home’s recruitment practices. Staff are trained and competent to do their jobs. EVIDENCE: At the time of the inspection it was noted on the staff rota, there was one Senior, four staff, one cook, a laundry worker and a domestic. It was noted that the home is very large and spread out, over two levels with three lounge areas and two dining rooms and this staff ratio is not adequate to meet the needs of the Service Users. The Manager said that currently she has more staff on holiday than usual and was making efforts to address this situation. Staff spoken to said there are not enough staff on duty and this is something they are concerned about. Staff files looked at had two references and a CRB and it was noted that there were a number of training certificates. Lodge (The) Collier Row DS0000027862.V254050.R01.S.doc Version 5.0 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 and 33 Service Users live in a home which is run and managed by a person fit to be in charge, the Manager is not trained to NVQ level 4 management training. The home is run in the best interests of Service Users. EVIDENCE: During the Inspection the Manager was spoken to and said that they had recently employed another Manager. However this was not successful and the Manager said that she would remain the Registered Manager. The Manager still has not undertaken the NVQ level 4 management training, this was a Requirement from the previous inspection and this will be restated as a result of this inspection. The home is run in the best interests of the Service Users, the Residents and a visitor spoken to said how well the home is run. Lodge (The) Collier Row DS0000027862.V254050.R01.S.doc Version 5.0 Page 16 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 1 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 X 9 X 10 X 11 1 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 3 3 3 X X 3 X 3 STAFFING Standard No Score 27 1 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X X X X X Lodge (The) Collier Row DS0000027862.V254050.R01.S.doc Version 5.0 Page 17 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 Standard OP4 Regulation 14(1a,b,c, d)CSA200 0 Timescale for action The Registered Provider must 28/10/05 ensure that they fully assess all prospective Service Users and ensure that they do not admit any Service Users who fall outside of the homes registration category, failure to comply could result in the Commission taking legal action. This requirement has been repeated The Registered Provider must 01/11/05 ensure that after consultation with Service User prepare a Care Plan is prepared. The Registered Provider must 03/01/06 ensure that Service Users wishes at the time of their death are respected and documented on the Care Plan. This requirement has been repeated The Registered Provider is 03/01/06 required to arrange Adult Protection training for staff ensure that the procedures (including the reporting of the alleged abuse)to be followed are clear and fully understood by all
DS0000027862.V254050.R01.S.doc Version 5.0 Page 18 Requirement 2 OP7 15 (1) 3 OP11 15(1) 4 OP18 13 (6) Lodge (The) Collier Row 5 OP27 18(1 a) 6 OP27 18 7 OP31 10 staff working at the home. This requirement has been repeated The Registered Person is 15/11/06 required to review the staffing levels at the home and supply the Commission with the result of the review and with an action plan to ensure that staffing levels are increased. This requirement has been repeated The home must have ratios of 15/11/05 care staff on duty to meet the assessed needs of residents. This requirement has been repeated The Manager must complete her 31/12/05 NVQ level 4 management training. This requirement has been repeated 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 Lodge (The) Collier Row DS0000027862.V254050.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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