This inspection was carried out on 31st January 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.
CARE HOMES FOR OLDER PEOPLE
Minchenden Lodge Blagdens Lane Southgate London N14 6DD Lead Inspector
Tony Brennan Unannounced Inspection 31st January 2006 11:00 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 Minchenden Lodge DS0000010661.V270275.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. Minchenden Lodge DS0000010661.V270275.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Minchenden Lodge Address Blagdens Lane Southgate London N14 6DD 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) 020 8886 1222 020 8886 1222 Scimitar Care Hotels Plc Ms Maria A Simpkins Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Minchenden Lodge DS0000010661.V270275.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 10th October 2005 Brief Description of the Service: Scimitar Care Hotels PLC owns Minchenden Lodge. The company owns a number of other homes in the North London area. Minchenden Lodge is a long established home in a residential part of Southgate. There is easy access to public transport and shops. The home now has twenty-one single rooms and no longer has double rooms. The home is registered to care for twenty-five older people but this is no longer relevant given the new changes to the double rooms. The home aims to provide personal care only for older people. The aim of the home is to deliver good quality care in comfortable surroundings ensuring that service users needs are met as individually as possible. Minchenden Lodge DS0000010661.V270275.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken as part of the annual inspection process. The inspector also sought to confirm that the twenty areas for improvement identified at the last inspection were addressed. The inspection took place over one day. The registered manager, Maria Simpkins, assisted the inspector. The inspector spoke with four service users and two staff. The inspector observed care practice and interaction between service users and staff. The inspector toured the building and examined a number of records relating to the care and management in the home. What the service does well: What has improved since the last inspection? What they could do better:
Eighteen areas for improvement were identified at this inspection. Care plans did not provide detailed information on how to support those who live at the home. This meant that their needs were not always being met. There were no assessments of individual’s risk of falls or planning to prevent falls. Training was found to be needed on adult protection, infection control and the use of fire extinguishers to ensure that people living in the home are safe and receive the care they need. The registered manager needs to complete the Registered Manager’s Award. The view of those who live at the home must be sought regarding the quality of the service provided. Not all staff had been supervised regularly to ensure that they were supported to provide the care and support that those living at the home needed. The fire risk assessment and evacuation procedure needs to be reviewed to ensure that all risk of fire is assessed and
Minchenden Lodge DS0000010661.V270275.R01.S.doc Version 5.0 Page 6 appropriate action will be taken in the event of fire to protect those living at the home. The automatic door close for bedroom No. 20 needs to be replaced as it does not work and poses a risk to the people who live at the home in the event of a fire. 50 of staff need to achieve NVQ in care to ensure that staff have the skills to meet the needs of those living at the home. Thirteen requirements made at the last inspection has not yet been met and has been restated in this report, with a new timescale for compliance. The date in bold type relates to the new timescale. Further information about unmet requirements can be found in the relevant standard. Unmet requirements impact upon the welfare and safety of service users. Failure to comply by the revised timescale will lead to the Commission for Social Care Inspection considering enforcement action to secure compliance. 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. Minchenden Lodge DS0000010661.V270275.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 Minchenden Lodge DS0000010661.V270275.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): Service users needs are not assessed prior to admission to the home. The home does not meet all of the assessed needs of service users. EVIDENCE: The registered manager explained that the issue of developing comprehensive assessments had not been addressed since discussions were taking place in the organisation on how this could be done. There was still a need to ensure that all service users needs were identified and met. Minchenden Lodge DS0000010661.V270275.R01.S.doc Version 5.0 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 the following standard(s): 7 8 9 10 Service users have insufficient information on how their needs are met. Service users risks of falls were being assessed and there was no plan for their prevention. Service users health needs are not being met. Records of medicines received into the home were complete. Service users’ right to privacy is respected. EVIDENCE: The inspector found that care plans had not been developed to include more personalised information on how the needs of service users are to be met. The registered manager explained that this had been identified in a number of homes within the Company and was being addressed by the organisation. The manager explained that a new format for care plans would be developed. The inspector suggested that there should be discussion of what information needs to be recorded as part of the care plans. Service users still had not been consulted about their preferred sleeping and waking times. This was not recorded as part of their care plans. Records showed that since the last inspection the weight gain and loss of service users has been monitored. A fall risk assessment and prevention plan still has not been put in place. Since the last inspection an accurate record of all medicines received into the home has been maintained. Training records showed that all staff administering medicines have received appropriate training from a pharmacist.
Minchenden Lodge DS0000010661.V270275.R01.S.doc Version 5.0 Page 10 Service users said that staff respect their privacy and always knock on their bedroom doors. Service users also said that staff take time to ask how they wished to be assisted. Staff understood how to assist service users in a way that ensures that their privacy is maintained. The inspector observed staff interaction with service users and found that they were accorded respect. Minchenden Lodge DS0000010661.V270275.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 14 Service users were not provided with sufficient and varied social and cultural activities. Service users are supported to maintain contact with relatives and other representatives of their choice. Service users are able to make choices about how they live in the home. EVIDENCE: A service user commented that no daily activities were being provided. The registered manager explained that there is still no programme of activities provided on a daily basis. On the day of the inspection no activities took place. The registered manager explained that entertainers come to the home twice monthly. Service users spoken to confirmed they had a choice as to whom they wished to see. Service users also said that there were no restrictions on visiting times. Service users also felt that staff were supportive and would assist them to spend time privately if they wished. Service users spoken to confirmed that they could make choices and control their lives, for example, choices of food. Minchenden Lodge DS0000010661.V270275.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): 18 Staff need to be trained in how to safeguard service users from abuse. EVIDENCE: Training records showed that staff had not received training in adult protection and how to prevent abuse. Minchenden Lodge DS0000010661.V270275.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): N/A None of these standards were inspected on this occasion. EVIDENCE: Minchenden Lodge DS0000010661.V270275.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): 29 30 Staff do not have the skills to meet all the needs of service users. Service users are protected by the home’s recruitment practices. EVIDENCE: Training records showed that staff had received training on first aid and that training was still required on infection control. Staff still needed training in the safe operation of the fire extinguishers. The home still needs to get 50 of staff qualified to NVQ in care at level 2. Staff files for new staff were found to contain all the required information. Minchenden Lodge DS0000010661.V270275.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 33 35 36 38 Service users live in a home that is well managed. Service users are not consulted about the quality of the service provided. Service users financial interests are protected by the home’s procedures. Staff are not appropriately supervised to ensure that the needs of service users are met. Service users and staff health and safety is not maintained. EVIDENCE: Service users said they felt that the registered manager was supportive and listened to them. The registered manager explained that she is not doing the RMA. The registered manager has had a number of years of relevant experience in care work. The registered manager explained that there was no system in place to consult service users about the quality of the care that they receive. The home does not hold any money on behalf of service users. Relatives or their representatives manage their finances. The registered manager explained that supervision has been started since the last inspection, but still needs to be given to all staff. The records of fire drills showed that night staff had taken part in a fire drill since the last inspection. The registered
Minchenden Lodge DS0000010661.V270275.R01.S.doc Version 5.0 Page 16 manager explained that she still needs to consult the Fire Service and review the fire risk assessment and evacuation procedure. The registered manager explained that fireguards still needed to be upgraded. Minchenden Lodge DS0000010661.V270275.R01.S.doc Version 5.0 Page 17 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 X X 2 2 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 X X X X X X X X STAFFING Standard No Score 27 X 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 2 Minchenden Lodge DS0000010661.V270275.R01.S.doc Version 5.0 Page 18 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 OP3 Regulation 14 Requirement Timescale for action 01/06/06 2. OP4 14 15 3. OP7 14 15(1) 4. OP7 15(1) The registered persons must ensure that a detailed assessment of all the needs of service users is carried out prior to admission. (The timescale of 01/01/06 was not met). The registered persons must 01/06/06 ensure that all the assessed needs of service users are met. (The timescale of 01/01/06 was not met). 01/06/06 The registered persons must ensure that there are up to date risk assessments. The registered person must also develop risk assessments to determine whether service users are at risk of developing pressure sores and that a care plan is put in place that outlines the actions to be taken to maintain tissue viability. (The timescale of 01/01/06 was not met). The registered persons must 01/06/06 ensure that the service users plans are detailed and personalised to ensure that their choices and preferences are reflected and can be met. These
DS0000010661.V270275.R01.S.doc Version 5.0 Page 19 Minchenden Lodge 5. OP7 15(1) 6. OP7 15(1) 7 OP8 14 15(1) 8. 9. OP12 OP18 16(2)(n) 13(6) 18(1) 10 11. OP28 OP30 18(1) 18(1) 12 OP31 18(1) care plans must be signed and dated by service users or their representatives. (The timescale of 01/01/06 was not met). The registered persons must ensure that all service users have care plans detailing their needs and the actions to them. (The timescale of 01/01/06 was not met). The registered persons must ensure that service users wishes are respected. Service users must be asked what their preferred waking and bed times are and these must be respected. Service users must also be asked about their preferred breakfast times. This must be recorded in the care plan. (The timescale of 01/01/06 was not met). The registered persons must ensure that the risk of falls is assessed and a prevention care plan is in place for those service users at risk. (The timescale of 01/01/06 was not met). The registered persons must ensure that there is a programme of activities in place. The registered persons must ensure that training is provided on adult protection for all staff. (The timescale of 01/01/06 was not met). The registered persons should ensure that 50 of staff achieve the NVQ at level two in care. The registered persons must ensure that staff receive training on: Infection control. (The timescale of 01/01/06 was not met). The registered persons must ensure that the registered
DS0000010661.V270275.R01.S.doc 01/06/06 01/06/06 01/06/06 01/06/06 01/06/06 01/07/06 01/06/06 01/12/06
Page 20 Minchenden Lodge Version 5.0 13 OP33 35(a) 14 OP36 18(2) 15 OP38 23(4)(d) 17. OP38 23(4) 18. OP38 23(4) manager undertakes the Registered Manager’s Award. The registered persons must ensure that a survey of service users, relatives and professionals is carried out to determine their views of the quality of the service provided. An action plan must be prepared for any areas of improvement identified in the survey. The registered persons must ensure that staff receive supervision six times a year and that this is recorded. (The timescale of 01/01/06 was not met). The registered persons must ensure that staff have training in the operation of fire extinguishers. (The timescale of 01/01/06 was not met). The registered persons must ensure that in consultation with the Fire Service, the fire risk assessment and the evacuation procedure are reviewed. (The timescale of 01/01/06 was not met). The registered persons must ensure that the fireguard on the door of bedroom No. 20 is repaired or replaced. (The timescale of 01/01/06 was not met). 01/07/06 01/06/06 01/06/06 01/06/06 01/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Minchenden Lodge DS0000010661.V270275.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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 Minchenden Lodge DS0000010661.V270275.R01.S.doc Version 5.0 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
