Inspection on 28/11/05 for Monread Lodge

This inspection was carried out on 28th 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

Monread Lodge 31/01/08

Monread Lodge 19/06/06

Monread Lodge 29/06/05

Monread Lodge 07/12/04

Monread Lodge 20/07/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Monread Lodge London Road Woolmer Green Hertfordshire SG3 6HG Lead Inspector Marian Byrne Unannounced Inspection 28th November 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 Monread Lodge DS0000019472.V267249.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. Monread Lodge DS0000019472.V267249.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Monread Lodge Address London Road Woolmer Green Hertfordshire SG3 6HG 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) 01438 817466 01438 817484 monread@lineone.net Monread Lodge Nursing Home Limited Mrs Anna Marrah Care Home 64 Category(ies) of Old age, not falling within any other category registration, with number (64) of places Monread Lodge DS0000019472.V267249.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. This home may accommodate 14 older persons who require personal care. This home may accommodate 50 older persons who require general, respite and convalescent nursing care. The home may accommodate one named service user who has not yet reached the age of 65 years of age. This condition will be removed when the service user attains the age of 65 years or permanently leaves the home for any reason. 29th June 2005 Date of last inspection Brief Description of the Service: Monread Lodge is registered to provide personal care and general nursing care (40 places) to elderly service users. The single storey home is situated between the villages of Woolmer Green and Knebworth. There are good parking facilities for visitors. All accomodation is in single rooms with en-suire bathrooms including a shower, wash hand basin and toilet. Assisted baths and toilets are also provided. There are a variety of lounges and quiet areas around the home with a central conservatory and dining area. Monread Lodge DS0000019472.V267249.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a positive inspection. It was carried out late morning and into the afternoon by two inspectors. On the day of the inspection service users were found to be well cared for and were appropriately dressed in freshly laundered clothes. The premises were clean and in the main odour free. There was an odour that could be associated with incontinence in one bathroom. Service users spoke positively of the care they receive. Other relatives were positive about the care their relatives are given. The inspector found the food to be tasty and of an acceptable quality. Lunch was served in two sittings with the most vulnerable sitting first. More thought needs to go into the serving of lunch as the people who were sitting at the tables were served after those who were in their rooms. Service users who are frail or have memory loss might find this difficult. Assisted feeding, was seen to be carried out with patience and care. Good interaction was observed between staff and service users. Screens were used to preserve the dignity of service users when a hoist was used to assist their mobility in communal areas. The training was up to date and adapted to meet the needs of the service users. What the service does well: What has improved since the last inspection? What they could do better: One of the inspectors observed a service user who was using a wheel chair to assist her mobility being moved by a member of staff without her being consulted in any way. This service had communication limitations and the staff members when asked why is wasn’t consulted replied that she didn’t know what’s happening anyway. This is not an acceptable way to deliver care and assistance. Monread Lodge DS0000019472.V267249.R01.S.doc Version 5.0 Page 6 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. Monread Lodge DS0000019472.V267249.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 Monread Lodge DS0000019472.V267249.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. The home has a Statement of Purpose and Service Users Guide that are regularly updated. All prospective service users are assessed prior to the home offering them a place. EVIDENCE: The home had recently updated its Statement of Purpose to reflect the change in its registration i.e. an increase in nursing beds and a reduction in its residential care beds. All prospective service users receive a thorough assessment prior to admission and then have their placement reviewed at regular intervals. Monread Lodge DS0000019472.V267249.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): 7,9 Care plans reflect the needs of the service users. Medicines are administered and recorded appropriately. EVIDENCE: The care plans are very clear and easy to follow. They are very personalised and give a good impression of the service user’s needs and their personality. Medicines were stored appropriately and a random audit of the records and medicines showed no anomalies. Monread Lodge DS0000019472.V267249.R01.S.doc Version 5.0 Page 10 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): These standards were not inspected. EVIDENCE: Monread Lodge DS0000019472.V267249.R01.S.doc Version 5.0 Page 11 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): The home has a complaints procedure. Service users are protected from abuse. EVIDENCE: The inspector tracked a complaint it was responded to in the required time and appeared to be satisfactorily investigated. Staff spoken with were aware of the home’s Whistle lowing policy and Hertfordshire’s Social Services’ Protection of Vulnerable Adults. One service user spoke of an incident that needed to be investigated the manager was keen to get the full details and said that she will investigate fully. Monread Lodge DS0000019472.V267249.R01.S.doc Version 5.0 Page 12 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): 19,26. The home is very well maintained. In the main it was clean, pleasant and hygienic. EVIDENCE: The home has a full time maintenance man who keeps the home well maintained. It was clean, bright and in the main odour free. The requirement left at the last inspection had been met, though there was a strong odour in one of the downstairs bathroom. Monread Lodge DS0000019472.V267249.R01.S.doc Version 5.0 Page 13 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): These standards were not inspected. EVIDENCE: Monread Lodge DS0000019472.V267249.R01.S.doc Version 5.0 Page 14 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): 31,33,37,38. The home is well managed and run in the best interests of the service users. Good record keeping was found in the home. The health and safety of the service users was protected. EVIDENCE: The Registered Manager has a great deal of experience in managing nursing homes and she runs the home in the best interests of the service users. She keeps up to date with good practice and keeps her own training up to date. On the day of the inspection visitors sought her out to speak with her. Records were available for inspection, these include all equipment being serviced regularly. Fire equipment is serviced annually. The home has a fire plan that is put in place through regular fire drills. Monread Lodge DS0000019472.V267249.R01.S.doc Version 5.0 Page 15 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 X 11 X X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X 3 X Monread Lodge DS0000019472.V267249.R01.S.doc Version 5.0 Page 16 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 OP9 Regulation 13 (2) Requirement The Registered Manager must ensure that the administration of medication is recorded appropriately. Timescale for action 29/06/05 2. OP19 23 (2)(d) This standard was met. The Registered Manager must 29/06/05 ensure that odours that could be associated with incontinence are eliminated. The odour in the downstairs bathroom must be eliminated. 3. OP29 17Sch4&1 9Sch2 This standard was not met. The Registered Manager must ensure that CRB checks have been cleared prior to staff commencing employment. This standard was met. 29/06/05 Monread Lodge DS0000019472.V267249.R01.S.doc Version 5.0 Page 17 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 OP15 Good Practice Recommendations The Registered manager should review how lunch is served to ensure the most vulnerable service users wait for as short a time as possible in the dining room. Monread Lodge DS0000019472.V267249.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ 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 Monread Lodge DS0000019472.V267249.R01.S.doc Version 5.0 Page 19 - 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!