Inspection on 02/08/05 for Lord Harris Court

This inspection was carried out on 2nd August 2005.

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

The inspector 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

Lord Harris Court 31/01/09

Lord Harris Court 31/01/07

Lord Harris Court 30/06/06

Lord Harris Court 17/01/06

Lord Harris Court 22/02/05

Lord Harris Court 05/07/04

Lord Harris Court 20/01/04

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 LORD HARRIS COURT Lord Harris Court Mole Road Sindlesham Wokingham, RG41 5EA Lead Inspector Susan Burton & Lorna Somerville, Pharmacy Inspector. Unannounced 2 August 2005 nd 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 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. LORD HARRIS COURT H52 01 11003 Lord Harris Court V2322485 020805 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Lord Harris Court Address Mole Road Sindlesham Wokingham Berks RG41 5EA 0118 9787496 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Royal Masonic Benevolent Institution Mrs Mary Tong Old age, not falling within any other category (OP) 81 Category(ies) of Old age, not falling within any other category registration, with number (OP) of places LORD HARRIS COURT H52 01 11003 Lord Harris Court V2322485 020805 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 The number of persons for who accommodation is provided for nursing patients at any one time shall not exceed 44. Date of last inspection 280405 Brief Description of the Service: Lord Harris Court is Royal Masonic Benevolent Institution Home that provides accommodation and care for up to eighty-one service users over the age of sixty-five years, of which up to forty-four service users may require nursing care. Lord Harris Court is situated in Sindlesham and is close to local shops, supermarkets and train station.There is an in-house shop one day a week, and transport in the homes mini bus to local shops for those more mobile. There are a number of garden areas and 3 large lounges for the residents and their visitors to use and a large dinning room.The home has a a wide ranging activity programme, a library and hairdressing facilities. LORD HARRIS COURT H52 01 11003 Lord Harris Court V2322485 020805 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced inspection on Tuesday 2nd August 2005, which commenced at 8:50 a.m. and finished at 17:10 p.m. A pharmacy inspection also took place during this time with a Pharmacy Inspector from the Commission for Social Care and Inspection. This was a generally positive inspection, which found the home had been making progress towards meeting the national minimum standards. The registered manager was off sick at the time of inspection and an acting manager was covering the home. One of the two deputy managers has been on long-term sick leave and there are also a number of staff vacancies at the moment; this has impacted on the residents who feel a little unsettled with the changes and use of agency staff. The home is currently in the final stages of completing an extension which will add an extra 13 bedrooms to the home, the registration of this extension is due to be completed in the near future. The Pharmacy Inspector issued an immediate requirement in regard to medication being administered which did not follow recommended guidance. What the service does well: What has improved since the last inspection? Documentation in the home has generally improved, although care plans still need further work. Requirements from the last inspection have been acted upon for example: recruitment practices have improved, pre-admission LORD HARRIS COURT H52 01 11003 Lord Harris Court V2322485 020805 Stage 4.doc Version 1.30 Page 6 assessments are more thorough and the home is now more able to demonstrate that it can meet the needs of the residents. The home has a program of refurbishment for the interior of the home, new armchairs are on order and certain areas of the home are being decorated What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. LORD HARRIS COURT H52 01 11003 Lord Harris Court V2322485 020805 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection LORD HARRIS COURT H52 01 11003 Lord Harris Court V2322485 020805 Stage 4.doc Version 1.30 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 standard(s) 3, 4 Residents have their needs fully assessed before they are admitted. The home is able to demonstrate that it meets the needs of residents including those with more specific care needs. EVIDENCE: Evidence from pre-admission assessments seen on the day of inspection support that information gathering for assessment has improved and more detail is now recorded to ensure that the prospective resident will have his/her needs met. The home was able to demonstrate by its care plans and other records that it is able to effectively meet the needs of those with more specific care needs, while remaining within its registration criteria. The acting manager advised the inspector of the training that has been undertaken and that is planned to ensure staff fully understand and are aware of the wide range of needs of the residents. LORD HARRIS COURT H52 01 11003 Lord Harris Court V2322485 020805 Stage 4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 The residents’ health needs are generally well detailed on the care plans. The assessments of nutritional and psychological needs are not effectively documented and linked to other care needs. Staff responses to emergency call bells need improvement. Progress has been made on improving the arrangements for medication, particularly with regard to documenting medication administration. EVIDENCE: The care plans examined on the day of inspection showed improvements in the depth of detail recorded, and evidence consultation with the residents or their family. Evidence was seen of regular reviews and documents were signed and dated by staff. Care plans had very basic nutritional assessments, which did not reflect the other care needs of the residents and therefore were not effective. Residents’ psychological health needs are not documented. The home needs to ensure that residents’ emotional and psychological health is monitored regularly and that preventative and restorative care is provided when necessary. The activities officer has regular one-to-one time with many of the residents and has become more aware of the emotional and social needs of individuals, LORD HARRIS COURT H52 01 11003 Lord Harris Court V2322485 020805 Stage 4.doc Version 1.30 Page 10 which may be of some importance to their physical well-being. This information is not documented within the care plans and does not appear to be utilised effectively or acknowledged in the records. During a visit to one of the more high dependency lounges a member of staff needed to use the emergency call bell for assistance. The inspector observed that some staff responded in a very relaxed manner and did not appear to take on board the situation until the inspector stated that help was needed. The home is advised to review its practice and procedures when responding to emergency call bells. Storage arrangements for medication were found to be acceptable in the home. Medication administration charts were looked at and found to be well completed, with clear reasons recorded for any doses of regular medication omitted. It needs to be ensured that medication is always given as intended by the prescribing doctor. There was a medication found for one resident, where doses in excess of the maximum were being given, and an immediate requirement was made at the inspection to stop administering this dose, and for the GP to be consulted. Some residents are responsible for taking their own medication and they have documented risk assessments available in their care plans. Residents can retain responsibility for their own medicines if they wish and policies and procedures to protect residents are in place for this. At the moment there is no system in place for the removal of unwanted medication from the home, now that the pharmacy can no longer take this back, and it is a requirement to make arrangements for the collection of this waste in the future. LORD HARRIS COURT H52 01 11003 Lord Harris Court V2322485 020805 Stage 4.doc Version 1.30 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 standard(s) 12,13,14,15 Residents in the home are satisfied with the activity programme provided. Contact is maintained with family and friends and the general community. The home enables the residents to exercise choice and control over their lives. Residents receive an appealing balanced diet in pleasant surroundings although some residents found the menus to be too repetitive. EVIDENCE: The inspectors spent time talking to the home’s activity organiser and was able to see from her contact sheets the different activities that residents take part in. Residents spoken to confirmed their satisfaction with the number and variety of activities and entertainment that is provided. The activity programme includes computer lessons, keep fit, indoor bowls, music club afternoons, video club afternoons, trips to the local shops, outings to the countryside and coffee, scrabble, beetle drives, and bingo. For those not able to leave their rooms the activity officer takes post and papers to them and will sit and chat, she will also undertake any shopping requests and ensures the mobile library visits the residents, she provides manicures and will also spend time with individuals on a one-to-one basis. The notice board displayed regular visits out to the local shops and visits out to the local countryside with the coffee stop along the way. Residents enjoy the monthly visits from the local vicar who provides communion in the homes own chapel. LORD HARRIS COURT H52 01 11003 Lord Harris Court V2322485 020805 Stage 4.doc Version 1.30 Page 12 The home keeps a record of the choices the residents have with their evening and morning routines, this includes what time somebody wishes to retire, their choice of drink and what they want for breakfast and any special requests. The inspector was able to speak to visiting relatives who were able to confirm their satisfaction for the care provided to their family members. The inspector visited the home’s kitchen and observed that it was clean and tidy and well-organised. The home had been visited by an Environmental Health Officer in July and no major concerns were found. The catering arrangements are subcontracted out rather than being provided by the home. The chef manager was qualified and experienced in providing balanced diets for the residents. Alternative meal choices are always available, meal times are very accommodating and very flexible. Menus are displayed on each table which are laid with linen tablecloths and napkins giving the dining room a hotel style ambiance. Residents spoken to found the quality of the meals generally quite satisfactory but some had a problem with the repetitiveness of the menus. LORD HARRIS COURT H52 01 11003 Lord Harris Court V2322485 020805 Stage 4.doc Version 1.30 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 standard(s) 16,18 in part Residents’ complaints are documented and acted on. The home is monitoring any incidents of bruising more effectively, as required from the previous inspection. EVIDENCE: The home’s complaints log had one documented entry; on examination the inspector found the acting manager had carried out an investigation and had responded appropriately to the residents concerns. A requirement from the previous inspection was that any incident or accident that resulted in bruising on a resident was recorded appropriately and investigated. From a review of care plans, accident book and other documents the inspector was satisfied that the home had improved its monitoring and documentation and had met to the requirement. LORD HARRIS COURT H52 01 11003 Lord Harris Court V2322485 020805 Stage 4.doc Version 1.30 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 standard(s) 19,20,21,26 Lord Harris Court is well maintained, comfortable and homely. The new extension was not registered at the time of inspection and therefore not inspected at this time. The home provides a variety of comfortable lounges for residents, and has a programme of planned refurbishment. Some bathroom facilities are currently being improved. The home was seen to be clean and tidy. Staff procedures and practices for the control of infection were not seen as satisfactory. EVIDENCE: The inspector had a tour of the building and was able to see a number of areas being refurbished and decorated. The acting manager advised that new furniture was on order to replace some armchairs and sofas that were too low and are no longer suitable. The organisation has built a new 13 bed extension on the top of the first floor. The extension is not yet registered due to some works that need to be carried out to satisfy the local fire officer’s fire safety requirements. LORD HARRIS COURT H52 01 11003 Lord Harris Court V2322485 020805 Stage 4.doc Version 1.30 Page 15 The home has three large lounges, one of which has a stage and piano for any entertainment activities that may take place. The acting manager showed the inspector number of areas, which were in various stages of redevelopment. The home has begun a programme to improve and upgrade two of its assisted bathrooms. From a tour of the building the inspector could see that the home was kept clean and tidy, the inspector also observed a number of staff not adequately following procedures to prevent the spread of infection. The laundry was visited and was seen to be quite small for such a large home; hand washing facilities for the laundry staff were not easily accessible. Discussion took place with staff and the acting manager in regard to improving the transportation and handling of soiled linen around the home. The home is recommended to place in the sluices and in the laundry return guidance/posters for its staff on appropriate cross infection measures and hand washing techniques. At the time of the inspection the home had only two sluices in operation, the sluice on the ground floor which is used mainly by nursing staff is quite small and cramped and consideration should be given to extending this area. LORD HARRIS COURT H52 01 11003 Lord Harris Court V2322485 020805 Stage 4.doc Version 1.30 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 29 Requirement from the last inspection that the home’s recruitment procedure be developed to meet the standard and regulation has been acted upon. EVIDENCE: At the last inspection there was a lack of appropriate recruitment information which was required by regulation and a requirement was made to that effect. The recruitment files of two new members of staff were examined during this inspection, confirmation of identity was seen in place, references, POVA first checks and CRB checks and therefore the requirement was now seen as met. LORD HARRIS COURT H52 01 11003 Lord Harris Court V2322485 020805 Stage 4.doc Version 1.30 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31in part,32,33 The home is currently being managed by an acting manager who was seen as competent and capable. Residents in the home benefit from the organisations and the manager’s open and positive approach. Feedback is actively sought from the residents to ensure the home is run in their best interests. EVIDENCE: The home’s Registered Manager is currently off sick and the organisation has put an acting manager in place to cover her post. The acting manager demonstrated during the inspection that she was a competent manager and fully aware of her responsibilities. The home is going through a difficult period at the moment with changes and vacancies in the staff team. Residents have felt the effect of the changes and have been reassured by the organisations LORD HARRIS COURT H52 01 11003 Lord Harris Court V2322485 020805 Stage 4.doc Version 1.30 Page 18 Responsible Person, the Business Operations Manager and the acting manager at a recent residents meeting. Both the organisation and the home have a positive and open approach, which enables a clear sense of direction and purpose to be communicated to both the residents and the Commission for Social Care and Inspection. The home has recently conducted a resident satisfaction survey, which was made available for the inspection. A random sample of responses were reviewed around indicated that residents who live in the home are generally satisfied with the quality of life and the service provided, some less positive responses were seen in regard to the food. LORD HARRIS COURT H52 01 11003 Lord Harris Court V2322485 020805 Stage 4.doc Version 1.30 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 x x x x 2 STAFFING Standard No Score 27 x 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 3 x x x x x LORD HARRIS COURT H52 01 11003 Lord Harris Court V2322485 020805 Stage 4.doc Version 1.30 Page 20 no 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 8 Regulation 12 (1)a Requirement Nutritional screening is linked to all aspects of an individuals care needs, with any actions required by staff being fully documented. Residents psychological and emotional health is monitored regularly with any preventative and restorative care provided being fully documented. The procedures and practices in the home for the control of infection are in accordance with relevant legislation and published professional guidance. That arrangements are made for the safe collection and disposal of unwanted medication through a licensed waste disposal company. Records need to be kept of the medication collected from the home. Timescale for action 30/9/05 2. 8 12(1)a 30/9/05 3. 26 13(3) 30/9/05 4. 9 13 (2) 29/10/05 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 H52 01 11003 Lord Harris Court V2322485 020805 Stage 4.doc Version 1.30 Page 21 LORD HARRIS COURT 1. 2. 8 26 The home reviews its procedures and practices when answering emergency call bells. Home is recommended to display in sluices and in the laundry good practice guidance on hand washing techniques and appropriate procedures for the control of infection. LORD HARRIS COURT H52 01 11003 Lord Harris Court V2322485 020805 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection 2 Floor 1015 Arlington Business Park Theale RG7 4SA 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 LORD HARRIS COURT H52 01 11003 Lord Harris Court V2322485 020805 Stage 4.doc Version 1.30 Page 23 - 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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