Inspection on 12/12/06 for Northcourt Lodge

This inspection was carried out on 12th December 2006.

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

Northcourt Lodge 08/12/05

Northcourt Lodge 28/07/05

Northcourt Lodge 01/03/05

Northcourt Lodge 14/09/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Northcourt Lodge 65 Northcourt Avenue Reading Berkshire RG2 7HF Lead Inspector Robert Dawes 12 th Unannounced Inspection December 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 Northcourt Lodge DS0000011034.V320643.R01.S.doc Version 5.2 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. Northcourt Lodge DS0000011034.V320643.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Northcourt Lodge Address 65 Northcourt Avenue Reading Berkshire RG2 7HF 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) 0118 987 5062 0118 975 5007 Mr Harbhajan Surdhar Dr Ramnath Narayan Ms Rozina Hashwani Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places Northcourt Lodge DS0000011034.V320643.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. That rooms 9. 11, 15 and 22 are not to be occupied by service users with physical disabilities. 8th December 2005 Date of last inspection Brief Description of the Service: Northcourt Lodge is a care home accommodating 21 older people, with nursing for up to 17 of the 21 older people. The home is not registered to provide intermediate care or care for older people suffering from a diagnosed mental illness. The home is situated in a suburb of Reading and privately owned by Mr Harbhajan Surdhar and Dr Ramnath Narayan. Service users are accommodated in 21 single bedrooms, eight of which have en-suite facilities. Service users are charged between £450 and £650 per week. Northcourt Lodge DS0000011034.V320643.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced site visit which took place during the day on the 12th December 2006. The pre-inspection questionnaire completed by the manager, the eight service users’ questionnaires returned and the site visit were the main sources of information for the key inspection. During the site visit the inspector spoke with five service users; interviewed two members of staff and the manager; toured the premises; looked at records; case tracked; and observed the interaction between service users and staff. Twenty-one standards were assessed of which seven were exceeded and fourteen were met. No requirements or recommendations were made. What the service does well: What has improved since the last inspection? All medicines received are accurately recorded. Access to the laundry room has improved. All the radiators are now fitted with safety guards. All the policies and procedures have been reviewed. Northcourt Lodge DS0000011034.V320643.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Northcourt Lodge DS0000011034.V320643.R01.S.doc Version 5.2 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 Northcourt Lodge DS0000011034.V320643.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Number 3. Quality in this outcome area is good. New service users are admitted only on the basis of a full assessment being undertaken. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Files of recently admitted service users showed comprehensive pre admission assessments were undertaken. Northcourt Lodge DS0000011034.V320643.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Numbers 7, 8, 9 and 10. Quality in this outcome area is excellent. Service user’s health, personal and social care needs are set out in detailed and comprehensive individual plans of care. Service users’ health and personal care needs are well met. Staff adhere to the medication policies and procedures. Service users feel they are treated with respect and dignity. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Detailed and comprehensive individual plans were seen which covered all aspects of the health, personal and social care needs of the service users. They were reviewed every month. Individual plans contained all aspects of the health needs of the service user, including pressure sore charts, weight charts and diet requirements. Service users said; ‘ staff look after their health and personal care well’; ‘not rushed when they have a bath’; ‘nothing could be improved’; ‘staff listen to what you say, answer queries and respond’; ‘see specialists when needed’; Northcourt Lodge DS0000011034.V320643.R01.S.doc Version 5.2 Page 10 ‘very well looked after’; ‘clothes are clean’; ‘make sure you are happy’; and ‘the staff are always kind and helpful’. All the service users who returned their surveys said; ‘they always receive the care and support they need’; ‘the staff listen and act on what they say’; and ‘they receive the medical support they need’. Five said ‘staff are always available when they needed them’ and three said usually. Service users looked clean and presentable. The manager reinforces good quality of personal and health care, i.e. mouth care, dental care and adhering to moving and handling guidelines, at staff meetings and individually. Storage arrangements are adequate, and safe storage is provided for all types of medication. The temperature range is monitored in the medication refrigerator, by recording maximum and minimum temperatures. Clear administration records are available showing that medication is given as prescribed by the GP. Records are kept of returned medication no longer needed and the quantities of medicines received into the home. The home has clear policies and procedures for handling medication. No service user self medicates. Sufficient number of staff are trained to administer medication. A pharmacist visits every year to check the receipt, recording, storage, administration and disposal of medicines. Service users said; ‘staff are kind and respectful’; ‘ they can stay up to when they like’; and ‘they have access to a telephone’. Northcourt Lodge DS0000011034.V320643.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Numbers 12, 13, 14 and 15. Quality in this outcome area is excellent. Service users have their social, cultural, religious and recreational interests and needs well met. Service users maintain contact with family, friends and the local community. Service users are helped to exercise choice over their lives. Service users enjoy their meals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: An activity organiser is employed to provide a wide range of enjoyable and stimulating activities four to five times a week. These activities include cards, games, dominos, playing the keyboard, singsongs, gardening in the summer and exercise sessions. The organiser also arranges regular outings to concerts for up to eight service users and arranges for individual service users to be taken out to the shops and for walks. In addition; people from a local Church visit every other Sunday to lead a religious service; service users are enabled to attend local Church services and receive communion in the home; and two service users go out to a local day club once a week. Service users said there are plenty of activities and they can go out if they wish. The activities programme is on display. Northcourt Lodge DS0000011034.V320643.R01.S.doc Version 5.2 Page 12 All the service users who returned their surveys said there are always or usually activities arranged by the home that they can take part in. Service users said friends and relatives are always made welcome. Christmas celebrations are being arranged. Service users can handle their own financial affairs if they wish. Service users can bring personal possessions with them and have access to personal records. Service users said they have choice about what they do. Service users said they like the food and they have a choice at meal times. One service user who returned the survey said he/she always liked the meals; five said they usually like the meals and one said they are usually cold. The manager said if any meal is cold it is taken away and reheated. The menu showed a wholesome and nutritious diet was offered to the service users. Meal times are not rushed and dietary and cultural needs are catered for. Northcourt Lodge DS0000011034.V320643.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Numbers 16 and 18. Quality in this outcome area is good. Service users are confident that their complaints will be listened to, taken seriously and acted upon. Service users are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints procedure. Leaflets on how to make a complaint are given to service users and their relatives. The complaint book showed appropriate responses were made to complaints. All the service users who returned the surveys said they know how to make a complaint; six said they know who to speak to if they are not happy and two said usually. Service users interviewed said; ’they would go to the manager if they have a complaint but all the staff listen to them’; ‘staff listen and act on what you say’; ‘if things are not right you only have to go to the manager and things are put right’; and ‘the staff are always responsive if I am unhappy’. The Commission received one complaint since the last inspection. The Commission considered the response by the manager was satisfactory. The home has a vulnerable adults procedure (including whistle blowing). Accidents to service users are recorded. Staff receive Protection of Vulnerable Adult training. The Commission has received no allegations of abuse. Northcourt Lodge DS0000011034.V320643.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Numbers 19 and 26. Quality in this outcome area is good. Service users live in a safe, well maintained, clean and hygienic environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is safe, adequately maintained, and provides a comfortable and pleasant environment for the service users. All radiators now have protective guards and the garden is beginning to be cleared and fencing repaired. An appropriate response has been made to the Occupational Therapist’s inspection of the premises. On the day of the site visit the home was clean and hygienic. Service users said the home is always fresh and clean. Northcourt Lodge DS0000011034.V320643.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): Numbers 27, 28, 29 and 30. Quality in this outcome area is good. Service users needs are met by the numbers and skill mix of the staff. Over 50 of staff have achieved a NVQ 2 or above in care. The home operates a thorough recruitment procedure. Staff are trained and competent to do their jobs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home employs a manager, five registered nurses, twelve care staff, cook, cleaner and part time maintenance man. During the day a registered nurse and four care staff are on duty. In the evenings a registered nurse and three care staff are on duty. At night a registered nurse and a care worker are on duty. Staff interviewed demonstrated a good understanding of the conditions and needs of the service users and said staff support one another. Service users said ‘the staff are always kind and helpful’; ‘staff look after them well and they are happy at the home’; ‘nice feeling that you know staff will help you’; ‘staff make sure you are happy’. 58 of the care staff have a NVQ2 or above in care Staff records showed appropriate recruitment procedures are followed. Northcourt Lodge DS0000011034.V320643.R01.S.doc Version 5.2 Page 16 Records showed the home offers a comprehensive training programme including refresher training. New staff receive induction training and training in core areas of their work. Staff also attend courses to improve their English and on topics such as dementia to gain a better understanding of older peoples needs and conditions. Staff said they are instructed properly and consider the training offered provides them with the knowledge and skills to respond satisfactory to the needs of the service users. The manager has recently trained staff in response to the publication of the new Infection Control and Fire Safety regulations. Northcourt Lodge DS0000011034.V320643.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Numbers 31, 33, 35 and 38. Quality in this outcome area is excellent. The registered manager is qualified and competent to run the home and meet its stated purpose, aims and objectives. The home is run in the best interests of service users. Service users’ financial interests are safeguarded. The health, safety and welfare of service users and staff are promoted and protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has achieved a MSc in Social Policy, Planning and Management; the Registered Manager’s Award; is a NVQ assessor; and is a mentor for the Thames Valley University mentorship programme. Staff described her as having high standards, communicates a clear sense of direction, is hard working and respected. Service users said ‘she is a very kind lady’; ‘there was Northcourt Lodge DS0000011034.V320643.R01.S.doc Version 5.2 Page 18 no body better’; ‘the manager is always very helpful’; and ‘is capable and professional’. The standard of care in the home has noticeably improved since the manager was appointed. A detailed and comprehensive development/action plan for 2006-7 has been produced from the results of satisfaction questionnaires sent to service users and relatives; views expressed at staff meetings; feedback from service users meetings; and information from quality monitoring systems operating in the home. The proprietor and manager are committed to continue improving the standard of care provided. The manager said satisfaction questionnaires would be sent to service users and relatives twice a year. The Infection Control and Fire Safety policies and procedures have recently been reviewed in light of changing legislation. The home does not take responsibility for the finances of any of the service users. One service user handles his own financial affairs. The finances of the other service users are handled by relatives or appointed agents. Records showed all the necessary Health and Safety checks and inspections have taken place. Records showed all the service users have had appropriate risk assessments undertaken. The manager has responded appropriately to the recommendations made by recent inspections by a Health and Safety inspector and an Environmental Health Officer. The manager reminds staff at staff meetings and individually to adhere to the Health and Safety policies and procedures. The manager has implemented the new Infection Control and Fire Safety regulations. Six staff have a current first aid certificate. Northcourt Lodge DS0000011034.V320643.R01.S.doc Version 5.2 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 3 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 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 3 X X 4 Northcourt Lodge DS0000011034.V320643.R01.S.doc Version 5.2 Page 20 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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 Northcourt Lodge DS0000011034.V320643.R01.S.doc Version 5.2 Page 21 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Northcourt Lodge DS0000011034.V320643.R01.S.doc Version 5.2 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. 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