Inspection on 25/05/05 for Newgate Lodge (EMI) Ltd

This inspection was carried out on 25th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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.

Other inspections for this house

Newgate Lodge (EMI) Ltd 20/09/07

Newgate Lodge (EMI) Ltd 03/04/07

Newgate Lodge (EMI) Ltd 24/04/06

Newgate Lodge (EMI) Ltd 21/02/06

Newgate Lodge (EMI) Ltd 07/02/05

Newgate Lodge (EMI) Ltd 09/03/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Newgate Lodge (EMI) Ltd Newgate Lane Mansfield Nottinghamshire NG18 2QB Lead Inspector Susan Lewis Unannounced 25 May 2005, 10:00 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. Newgate Lodge (EMI) Ltd C53 C03 S41834 Newgate Lodge V229057 250505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Newgate Lodge (EMI) Ltd Address Newgate Lane Mansfield Nottinghamshire NG18 2QB 01623 622322 01623 621200 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) Paramdeep Kaur Lidder & Jasvinder Singh Lidder Vacant Care home 51 Category(ies) of DE Dementia, x 31 registration, with number OP Old age, x 20 of places Newgate Lodge (EMI) Ltd C53 C03 S41834 Newgate Lodge V229057 250505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: One named service user within the category of MD Service Users shall be within categories DE(31), OP(20) Date of last inspection 7 February 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 C53 C03 S41834 Newgate Lodge V229057 250505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was following a complaint received by the Commission. Therefore this inspection concentrates on the standards that are affected by the complaint. The registered person needs to ensure all outstanding requirements from the last inspection are met. The inspection took place over 6 hours. Three residents, five visitors and three staff were spoken with as well as the deputy manager and provider. What the service does well: What has improved since the last inspection? Some improvement on care plans has taken place but this has been hindered by the fact there is still no manager in post. It is hoped the new manager will be in post by July 19th 2005. Staff training has begun and more has been organised. This is a relatively new home that is undergoing ‘teething problems’. It is hoped once a manager is in post he will be able to resolve many of these issues. Newgate Lodge (EMI) Ltd C53 C03 S41834 Newgate Lodge V229057 250505 Stage 4.doc Version 1.30 Page 6 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 C53 C03 S41834 Newgate Lodge V229057 250505 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 Newgate Lodge (EMI) Ltd C53 C03 S41834 Newgate Lodge V229057 250505 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 and 6 Progress has been made on improving the care plans and although not yet up to standard it is clear that the management are in the process of completing this task. Residents are not completely assured at this stage that their needs will be met at the point of moving in. EVIDENCE: This home does not provide Intermediate Care. Four care plans were looked at for the purpose of this inspection. Work has started in improving the plans and evidence was seen that the two deputies are working their way through this task. Some of the plans still do not provide sufficient detail. The inspector has asked the proprietor to keep the Commission informed and updated of the progress the deputies are making in completing this task. Newgate Lodge (EMI) Ltd C53 C03 S41834 Newgate Lodge V229057 250505 Stage 4.doc Version 1.30 Page 9 Training has started regarding dementia awareness; staff confirmed that they had attended or are due to attend ensuring that the specialist service is based on current good practice and clinical guidelines. The deputy manager was asked to send a copy of the course contents to the Commission. The deputy manager and staff spoken with confirmed that moving and handling training had been completed for most staff. This was an immediate requirement at the last inspection. The plans looked at did not have resident contracts stating the terms and conditions of residence the Registered Person must ensure this is completed. Newgate Lodge (EMI) Ltd C53 C03 S41834 Newgate Lodge V229057 250505 Stage 4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 10 Work is still in progress to meet all the outstanding requirements. Residents are potentially being put at risk where staff make errors when drawing up care plans. EVIDENCE: As previously mentioned work has started on improving care plans. However staff must take care when filling out the new care plans that they do not put in contradictory information. One care plan viewed showed that there was cause for concern on the Nutritional Risk Assessment yet this was contradicted in the Pressure Care Risk Assessment, leading to no care plan being created for Pressure Care for this person. There was some evidence of resident or relative involvement in the creation of care plans on one file looked at. Care plans are not getting reviewed regularly. The deputy manager and the provider both felt that this would be remedied once the new manager was in post. Relatives spoken with all said that staff kept them informed of the care the resident was receiving and health care needs appear to be adequately met. Some of the requirements set at the last inspection still need to be addressed and they were not all covered during this inspection. These requirements are Newgate Lodge (EMI) Ltd C53 C03 S41834 Newgate Lodge V229057 250505 Stage 4.doc Version 1.30 Page 11 regarding the recording of accidents and the handover of information from one shift to the next. The registered person must ensure these are met. Medication was not fully inspected but staff were observed administering medication to residents, the storage appears to be of a good standard, within a well equipped Treatment Room. There are two drugs trolleys, one for each floor. Staff were observed to sign after administering the medication. Part of the complaint the Commission received was residents were not treated with respect and dignity. This was not upheld. Residents and relatives spoken with all confirmed that staff respected their privacy and dignity and this was observed during the inspection. Staff spoken with understood how to support this. A number of visitors spoken with spent a considerable amount of time at the home often visiting daily and for long periods of the day. Newgate Lodge (EMI) Ltd C53 C03 S41834 Newgate Lodge V229057 250505 Stage 4.doc Version 1.30 Page 12 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 and 15 Although the management have clearly tried to provide activities for residents there is still not enough to keep them active. The quality of food does need to improve to ensure that residents’ nutritional intake is not compromised. EVIDENCE: Part of the complaint received was that residents sat around all day doing nothing. This was partially upheld. Residents and staff spoken with said that although there were activities there could be more as they were only at the start of the week. One resident said that ‘it would be better if the activities were spread through the week a bit more’. On the day of the inspection the activities coordinators were there and residents were involved in quizzes, which residents clearly enjoyed. Residents said that they were able to get up when they wanted and stay in their room if they wished. The home has a multi faith chapel, which the proprietor said relatives used but they did not have any visiting clergy as yet. Care plans did indicate what faith if any and if they were practicing. The new manager must create links with local religious groups to ensure that where residents wish to continue to practice their faith they are able. Information on the activities is posted up for residents to see. The home provides ample space for visitors, they have their own small kitchen to make drinks in; residents can see visitors in private in an area of their Newgate Lodge (EMI) Ltd C53 C03 S41834 Newgate Lodge V229057 250505 Stage 4.doc Version 1.30 Page 13 choosing. Visitors spoken with confirmed that they were made to feel welcome. Residents’ bedrooms that were seen all had personal possessions in. Not all residents spoken with were aware of their right to access their care plans. Staff must remind residents regularly that this is their right. Part of the complaint received said that residents did not get any choice at meal times. This was partially upheld. The meal was not observed during the inspection, however there was evidence that choice was given, but residents all complained about the quality of the food saying it was ‘poor’ or ‘you don’t get a lot’. The quality of food must improve, and the choices document could be extended to include portion size. At the previous inspection a requirement was made regarding risk assessing hot drinks this was not fully assessed at this inspection and remains outstanding until the next inspection can confirm it has been completed. Newgate Lodge (EMI) Ltd C53 C03 S41834 Newgate Lodge V229057 250505 Stage 4.doc Version 1.30 Page 14 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 and 18 Residents are potential being put at risk of abuse by staff. EVIDENCE: The home has not received any complaints directly. All residents and relatives spoken with knew who to go to and all felt confident that the deputy managers or proprietor would sort any concerns out. The registered person must ensure that all information regarding complaints is available and in a form that shows what action has been taken. Part of the complaint received by the Commission concerned staff shouting at residents. This is upheld. Residents confirmed that this did sometimes happen, staff spoken with although when given scenarios regarding abuse all recognised that shouting constituted abuse and said would go to the deputy manager to report it, when asked if they had heard staff shout all said yes and no one had reported it. It is essential that all staff receive abuse awareness training as soon as possible. The registered person must inform staff that the complaint was upheld and that shouting at residents is unacceptable behaviour. It is recommended that all staff receive training regarding challenging behaviour. Newgate Lodge (EMI) Ltd C53 C03 S41834 Newgate Lodge V229057 250505 Stage 4.doc Version 1.30 Page 15 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) 26 Residents live a clean and pleasant environment. EVIDENCE: Part of the complaint received said towels were being stored in bathrooms. This is not upheld. The home was spotlessly clean on the day of the inspection with evidence of the two cleaners throughout the building. One small area of the building was noted to have an offensive odour, the proprietor immediately asked the cleaners to clean the carpet in that part of the corridor. The cleaners had access to good quality equipment to be able to do their job, they were positive about the role they played within the home. Residents spoken with all said their rooms ‘were kept clean and tidy’. Newgate Lodge (EMI) Ltd C53 C03 S41834 Newgate Lodge V229057 250505 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) 27, 29 and 30 There are insufficient trained and competent staff on duty to meet the needs of the residents. EVIDENCE: Staff rotas showed that there are sufficient care staff on duty, however as there is currently no manager this is having a detrimental effect on the home. The registered person is responsible for ensuring all outstanding requirements are met. The proprietor said that it is their intention to increase the handyman’s hours as they now realise that it is insufficient for a home of this size. They have now increased the night staff to four as required at the last inspection; again this must be kept under review and should be considered a minimum. Staff spoken with confirmed that they all had Criminal Record Bureau checks and had been asked to provide two references. Staff files were not fully inspected, as this did not constitute part of the complaint, they will be looked at in detail at the next inspection. The registered person must ensure that the requirement set at the last inspection is now met and evidence provided to the Commission. Part of the complaint was that staff did not receive training. This is not upheld. Staff spoken with confirmed that they were able to access all mandatory training and NVQ training and had recently attended a number of courses. The deputy manager said that staff had attended Manual Handling training recently. A matrix of staff training was seen in the manager’s office. Newgate Lodge (EMI) Ltd C53 C03 S41834 Newgate Lodge V229057 250505 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) 31 The home is currently without a manager and residents are potentially at risk. EVIDENCE: The home has been without a manager for several months, the previous acting manager left. The two deputies are currently doing what they can to provide management cover. The new manager is due to start in July 05 and an application must be submitted for registration purposes as soon as possible. As this inspection was primarily to look at the complaint received the rest of the standards in this section will be looked at the next inspection. Newgate Lodge (EMI) Ltd C53 C03 S41834 Newgate Lodge V229057 250505 Stage 4.doc Version 1.30 Page 18 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 2 2 2 x N/A 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 2 COMPLAINTS AND PROTECTION x x x x x x x 3 STAFFING Standard No Score 27 1 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 1 1 x x x x x x x Newgate Lodge (EMI) Ltd C53 C03 S41834 Newgate Lodge V229057 250505 Stage 4.doc Version 1.30 Page 19 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 OP2 Regulation 5 Requirement The registered person must ensure that a fully completed copy of the terms and conditions of the home is provided for all service users. Previous requirement 7/04/05 The registered person ensure that care plans accurately reflect the service users needs as stated in the assessment and where needs change that this is clearly documented as such. Previous requirement 7/04/05 The registered person must ensure that plans of care address challenging behaviour, giving staff clear directionto staff in how best to deal with it by the use monitoring and evaluation tools. The registered person must ensure that care plans are fully completed, devised from assessments, and include risk assessments and relevant specific action plans. Previous requirement 7/04/05 The registered person must ensure that care plans are reviewed regularly. Previous requirement 7/04/05 Timescale for action Immediate 2. OP3 14,15 Immediate 3. OP7 15 1st September 2005 4. OP7 14,15 1st September 2005 5. OP7 14,15 1st September 2005 Page 20 Newgate Lodge (EMI) Ltd C53 C03 S41834 Newgate Lodge V229057 250505 Stage 4.doc Version 1.30 6. OP7 14,15 7. OP8 17 8. OP8 12,13,14, 15,17 9. OP12 12,13 10. OP15 12,13 11. OP15 16 12. OP16 17 13. OP18 13 14. OP29 7,8,19 The registered person ensure there is written evidence of service users/relatives agreement to the care plan. Previous requirement 7/04/05 It is required that the registered person ensure accident records are accurate and completed on every occasion. Previous requirement 7/04/05 The registered person ensure that details of service users injuries are discussed in handover, fully documented and followed up in care notes. Previous requirement 7/04/05. The registered person shall consult residents about social interests and make arrangementsfor them to engage in local, social and community activities. The registered person ensure the health and safety of service users regarding the serving of hot tea and provide risk assessments where appropriate. Previous requirement 7/04/05 The registered person shall provide adequate quantities, suitable, wholesome nutritious food which is varied. The registered person must formalise the complaints procedure and ensure all complaint details are available for inspection. Previous requirement 7/04/05 The registered person will make arrangements to ensure that all staff receive training to prevent service users being harmed or suffering abuse or being placed at risk. Staff must also be told it is not acceptable to shout at residents. The registered person must ensure that staff files are 1st September 2005 Immediate Immediate 1st September 2005 1st September 2005 1st September 2005 1st September 2005 Immediate. Immediate Page 21 Newgate Lodge (EMI) Ltd C53 C03 S41834 Newgate Lodge V229057 250505 Stage 4.doc Version 1.30 15. OP31 8,9,19 16. OP27 18 updated to include all information required in schedule 2 of the regulations. Previous requirement 7/04/05 The registered person shall appoint manager and inform the Commission for Social Care Inspection The registered person shall having reard to the size of the care home, the statement of purpose and needs of the service users ensure that at all times suitably qualified, competent and experienced persons are working at the home. The registered person must ensure that a suitably qualified manager is in post. 19th July 2005 19th July 2005 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. 4. 5. 6. 7. 8. 9. Refer to Standard OP4 Good Practice Recommendations Provide evidence of specialist care for people with dementia, in terms of visual cues, practices and activities. Ensure that there is full documentation regarding relatives/service users wishes/requests, which contravene good practice. Care plans should be reviewed monthly Ensure that nutritional records indicate how much portion is taken. The ‘choices’ document regarding meals should be extended to record a choice of portion size to accommodate individual preferences. Ensure all staff is trained in dealing with challenging behaviour Where service users wish to have rugs in their bedrooms, an appropriate risk assessment and disclaimer should be in place. C53 C03 S41834 Newgate Lodge V229057 250505 Stage 4.doc Version 1.30 Page 22 OP7 OP7 OP8 OP15 OP18 OP18 Newgate Lodge (EMI) Ltd 10. 11. 12. 13. OP30 OP30 OP36 OP38 14. OP7 Induction topics should be signed and dated when completed. The induction provided should be to National Training Organisation Standards. Ensure that there is review of policies and procedures to ensure practices within the home are improved. The Registered Provider should review the issues in relation to poor health and safety practices highlighted at the inspection, to address competency and fitness levels, of the staff employed and ensure adequate and appropriate training is provided alongside revised policies and procedures. Care workers should be trained so as they are able to review care plans Newgate Lodge (EMI) Ltd C53 C03 S41834 Newgate Lodge V229057 250505 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection 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 C53 C03 S41834 Newgate Lodge V229057 250505 Stage 4.doc Version 1.30 Page 24 - 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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