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Inspection on 21/02/06 for Newgate Lodge (EMI) Ltd

Also see our care home review for Newgate Lodge (EMI) Ltd for more information

This inspection was carried out on 21st February 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home continues to provide a pleasant environment for residents to live in, particularly the downstairs. Residents spoken with were happy with their bedrooms and felt that they had everything they needed. They said that staff were caring and they gave support when needed.

What has improved since the last inspection?

The metal caging that was around the perimeter wall has started to be removed. The deep fat fryer has been relocated and the laundry has now got a water supply that meets regulation. The handling of medication has improved and staff are now much more conscious of knocking on doors. The acting manager has ensured that staff files are kept in good order and appropriate checks are made.

What the care home could do better:

Although work is obviously taking place on care plans more work must be done to ensure that there is enough detail so it is clear exactly what care each a resident needs and how those needs are to be met. Residents must also be risk assessed for keys to their bedroom and ensure that they are risk assessed accordingly. Where the home is still within timescale to meet requirements the registered person must take this opportunity to ensure that those standards are met. These are quality reviewing the care and making care plans available to residents. The registered must also ensure that a financial plan is available for inspection to provide evidence to show that this is a well run business.

CARE HOMES FOR OLDER PEOPLE Newgate Lodge (EMI) Ltd Newgate Lodge Newgate Lane Mansfield Nottinghamshire NG18 2QB Lead Inspector Susan Lewis Unannounced Inspection 21st February 2006 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 Newgate Lodge (EMI) Ltd DS0000041834.V277744.R01.S.doc Version 5.1 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. Newgate Lodge (EMI) Ltd DS0000041834.V277744.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Newgate Lodge (EMI) Ltd Address Newgate Lodge Newgate Lane Mansfield Nottinghamshire NG18 2QB 0162 362 2322 0162 362 1200 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) Paramdeep Kaur Lidder Jasvinder Singh Lidder Vacant Care Home 51 Category(ies) of Dementia (31), Old age, not falling within any registration, with number other category (20) of places Newgate Lodge (EMI) Ltd DS0000041834.V277744.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. One named service user within the category of MD Service Users shall be within categories DE(31) , OP(20) Date of last inspection 15th November 2005 Brief Description of the Service: Newgate Lodge is a new purpose built home for 51 service users in the older age and dementia categories. It is laid out in four sections with corresponding dining and seating facilities. All bedrooms are ensuite and well maintained and decorated. In addition to this there are 8 toilets, 4 bathrooms with assisted bathing facilities and 4 showers. Service users are able to bring in personal belongings and furniture within reason. Lockable storage is available in bedrooms. There are 6 sitting rooms and a relatives room plus sufficient outside space for all service users. Grab rails are in corridors and radiators are low surface temperature with the exception of the reception area, which has covered radiators. Newgate Lodge (EMI) Ltd DS0000041834.V277744.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the third unannounced inspection of the 2005/06 inspection year and was carried out over 7 hours and focussed on outstanding requirements set at the last inspection. Residents, staff and relatives were spoken with during the inspection. Staff and care records were also inspected. A tour of the grounds took place to look at related requirements and only a partial tour of the internal of the home was carried out as these standards had been looked at, at previous inspections. What the service does well: What has improved since the last inspection? 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. Newgate Lodge (EMI) Ltd DS0000041834.V277744.R01.S.doc Version 5.1 Page 6 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 Newgate Lodge (EMI) Ltd DS0000041834.V277744.R01.S.doc Version 5.1 Page 7 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): EVIDENCE: These standards were not assessed during this inspection for details regarding these standards please see the report dated 15th November 2005. Newgate Lodge (EMI) Ltd DS0000041834.V277744.R01.S.doc Version 5.1 Page 8 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 and 10 Residents are yet to be fully involved in their care planning, medication is well organised minor adjustments need to be made to minimise any risk. EVIDENCE: Three care plans were viewed for the purpose of this inspection and although plans still do not provide enough detail in discussion with staff it was clear that they knew how to provide care to each resident they worked with. Residents spoken with were aware that they had key workers but not that they had care plans that they could access. It is recommended that residents be regularly reminded that they can access their plan whenever they want to. Each plan viewed had a great deal of information in regarding risk assessments and activities of daily living, however the plan did not then go on to say how each identified need would be met. This issue was discussed with the acting manager and deputy manager as to how this standard could be met. Although this is still an outstanding requirement an extension will be given to give time for the acting manager to meet this standard. Newgate Lodge (EMI) Ltd DS0000041834.V277744.R01.S.doc Version 5.1 Page 9 A requirement was left at the last inspection regarding providing evidence of service users or relatives’ agreement to care plans. Although some care plans viewed had some evidence of their involvement not all plans showed this. The registered person must ensure that where possible evidence is provided in all care plans to show that they are involved in creating and reviewing care plans. Two requirements were made at the last inspection regarding medication. Firstly, that the registered person must ensure that administration of controlled drugs be witnessed by a second person, evidence was seen that this has now been met and minimises the risk of incorrect administration to a resident. The second requirement was that the registered person must ensure that they must consult appropriately regarding the disposal of medication. Evidence was seen that this has been done and appropriate measures are now taken to ensure that medication to be removed from the building are recorded correctly. In looking at the medication administration record sheets it was clear that where staff had hand written additions to sheets that these had not been countersigned, it is strongly recommended that this is done to minimise any risk of incorrect medication being given to a resident. In discussion with the acting manager it was evident that the home does not use covert administration of medication. However, it is recommended that this be included in the homes local policy and procedures of medication administration and to keep it under review. Residents spoken with said that staff always knock on the door and wait before entering. Staff spoken with understood the need to maintain residents’ privacy and dignity. A requirement had been set at the last inspection regarding this and is now considered to be met. Newgate Lodge (EMI) Ltd DS0000041834.V277744.R01.S.doc Version 5.1 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): 13 Residents are able to maintain contact with the local community. EVIDENCE: During the course of the inspection residents were seen to be involved in exercise activities and residents spoken with who had taken part said that they had enjoyed it. A requirement had been made at the last inspection regarding a resident making a request to go into town. This is no longer relevant as the resident in question has deteriorated. However the registered person must ensure that where residents make requests to access community facilities that these must be met in accordance with the statement of purpose and service users guide. Residents spoken with confirmed that a local vicar comes to the home regularly to carry out services. Newgate Lodge (EMI) Ltd DS0000041834.V277744.R01.S.doc Version 5.1 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): 16 There is a thorough complaints procedure that protects residents. EVIDENCE: The Commission has received a number of complaints over the last few weeks; these have been passed back to the acting manager to investigate. The acting manager has provided the inspector with evidence of what investigation took place and what the outcome was and what action has been carried out if any. Residents and relatives spoken with all said that they knew who to complain to and felt confident that it would be dealt with. Newgate Lodge (EMI) Ltd DS0000041834.V277744.R01.S.doc Version 5.1 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, 24 and 26 The environment is homely and maintained in a safe manner to minimise risk to residents. EVIDENCE: A requirement was left at the last inspection regarding the metal caging attached to the outside garden wall. Evidence was seen that the process has started to remove it. It has been removed in all but one area. A requirement was left to ensure all residents who wish to have a key are provided with one subject to a risk assessment. Residents spoken with said that they did not have a key nor had they been asked if they wanted one. The registered person must ensure that all residents are enabled to have a key if they so wish to maintain their privacy. A requirement was made at the last inspection regarding the water to the washing machines must comply with the Water Supply (Water Fittings) 1999 Act. Evidence was seen to evidence that this has been complied with. Newgate Lodge (EMI) Ltd DS0000041834.V277744.R01.S.doc Version 5.1 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): 29 Recruitment procedures are robust and protect residents. EVIDENCE: A requirement was made at the last inspection regarding ensuring the recruitment procedures were robust and showed evidence that reference and Criminal Records Bureau checks were obtained prior to them starting work. Five staff files were looked at and provided evidence that this standard is now met. Newgate Lodge (EMI) Ltd DS0000041834.V277744.R01.S.doc Version 5.1 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, 32, 33, 34, 37 and 38 The acting manager provides clear leadership to staff and residents benefit from this guidance. EVIDENCE: The acting manager is due to undergo his fit person interview with the Commission on 22nd February 2006. Residents, relatives and staff all spoke highly of the manager. Staff said that he gave a clear view of the standards expected and that he shared information regarding inspections with them and was supportive and helpful. The acting manager has created a quality file, which looks at all aspects of the home and how to maintain standards. However a requirement was left at the last inspection on establishing a system to review quality within the home. This has yet to be done. Newgate Lodge (EMI) Ltd DS0000041834.V277744.R01.S.doc Version 5.1 Page 15 The acting manager has worked closely with the Commission in raising standards within the home and it was clear from discussion with the acting manager that he will continue to work to improve and maintain standards. The date that this must be met by is 01/04/06 and therefore is within timescale. The acting manager was unable to provide the inspector with a business or financial plan. The registered person must ensure that this is open to inspection and reviewed annually to ensure that residents benefit from living in a well managed home. In discussion with residents it was clear that they were unaware of their care plans and did not know they could access them. A standard had been made at the last inspection to ensure all resident who were able could access his or her plans. This requirement at the time of the inspection was still within timescale 01/03/06. The registered person must ensure that this is met. A requirement was made at the last inspection regarding the deep fat fryer and it location as it could be a risk to those who use it. It has now been moved and this standard is considered met. Newgate Lodge (EMI) Ltd DS0000041834.V277744.R01.S.doc Version 5.1 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 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 X 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X X X X 2 X 3 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 3 3 2 2 X X 2 3 Newgate Lodge (EMI) Ltd DS0000041834.V277744.R01.S.doc Version 5.1 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 OP7 Regulation 15 Requirement The Registered Person must ensure that after consultation with the service user or representative pf his, prepare a written plan as to how the service user’s needs in respect of his health and welfare are to be met. The plans should be written in sufficient detail to ensure that care staff understand the action to be taken to meet the needs of the service user. (Outstanding requirement from 01/02/06) The Registered Person shall make suitable arrangements to ensure that the care home is conducted in a manner, which respects the privacy and dignity of service users. Residents must be provided with a key unless their risk assessment suggests otherwise. (Outstanding requirement from 1/02/06) The Registered Person shall establish and maintain a system for reviewing at intervals, and improving the quality of care provided at the care home. DS0000041834.V277744.R01.S.doc Timescale for action 01/04/06 2 OP24 12 01/04/06 3 OP33 24 01/04/06 Newgate Lodge (EMI) Ltd Version 5.1 Page 18 4 OP34 25 5 OP37 15 The Registered Person shall if the Commission so requests, provide the Commission with such information and documents as it may require for the purpose of considering the financial viability of the care home, including the annual accounts. The registered person must ensure that there is a business plan for the home. The Registered Person shall make the service user’s plan available to the service user. 01/04/06 01/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP7 OP9 OP9 Good Practice Recommendations Remind residents that they have care plans and that they can access them. That where MAR sheets are hand written that they are signed and countersigned to minimise risk of error. A policy and procedure regarding covert medication in line with UKCC policy. See www.ukcc.co.uk Newgate Lodge (EMI) Ltd DS0000041834.V277744.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 Newgate Lodge (EMI) Ltd DS0000041834.V277744.R01.S.doc Version 5.1 Page 20 - 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. 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