Inspection on 28/07/05 for Northcourt Lodge

This inspection was carried out on 28th July 2005.

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.

Other inspections for this house

Northcourt Lodge 12/12/06

Northcourt Lodge 08/12/05

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 Berks RG2 7HS Lead Inspector Ruth Lough 2nd Inspector - Lorna Sommerville Unannounced 28 July 2005 09:45 am 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. NORTHCOURT LODGE H51-H01-S11034-Northcourt Lodge-V235266280705-Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Northcourt Lodge Address 65 Northcourt Avenue, Reading, Berks, RG2 7HS 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) 0118 9875062 Mr H Surdhar and Dr R Narayan Care Home (CRH) 22 Category(ies) of Old age, not falling within any other category registration, with number (OP) of places NORTHCOURT LODGE H51-H01-S11034-Northcourt Lodge-V235266280705-Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 1 March 2005 Brief Description of the Service: Northcourt Lodge is a care home for 22 older people with low to middle dependency needs. The home does not provide intermediate care, dementia care or nursing care. The home is situated in a suburb of Reading and privately owned by Mr Harbhajan Surdhar and Dr Ramnath Narayan. Service users are currently accommodated in one double and nineteen single bedrooms. Some considerable refurbishment has been undertaken in the home to develop the home inclusive of further bedrooms with ensuite facilities. NORTHCOURT LODGE H51-H01-S11034-Northcourt Lodge-V235266280705-Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection visit to review the quality of service provided and the outcomes for the service users living there. The inspectors also reviewed the outstanding requirements and recommendations made during a previous inspection visit in March. The inspection visit took approximately 4.45 hours and involved looking at records, tour of the home and discussions with service users and staff. The Registered Manager’s post is vacant and the proprietors have employed a new person to the role and at the time of the inspection is in the process of application for registration with the CSCI. The Manager was not in the home at the time of inspection but Mr Harbhajan Surdhar, Proprietor, was available to support the staff during the process. Six immediate requirements were made during this visit in regard to the safety of service users, staff and visitors. What the service does well: What has improved since the last inspection? What they could do better: That the health, safety and welfare of service users, staff and visitors are put at risk by the home not implementing safe working practices. Please contact the provider for advice of actions taken in response to this NORTHCOURT LODGE H51-H01-S11034-Northcourt Lodge-V235266280705-Stage 4.doc Version 1.40 Page 6 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. NORTHCOURT LODGE H51-H01-S11034-Northcourt Lodge-V235266280705-Stage 4.doc Version 1.40 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 NORTHCOURT LODGE H51-H01-S11034-Northcourt Lodge-V235266280705-Stage 4.doc Version 1.40 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) Standards not inspected. EVIDENCE: As above. NORTHCOURT LODGE H51-H01-S11034-Northcourt Lodge-V235266280705-Stage 4.doc Version 1.40 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 standard(s) 9 and 10 Arrangements have been made for administration of medication, but clearer records are needed to show that residents receive their medication as prescribed by their doctor. Service users can be confident that the staff ensure their privacy and dignity. EVIDENCE: The service users commented to the inspector that the staff maintain privacy and dignity at all times whist carrying out personal care with them. They also commented that all the staff team were friendly, courteous and polite. Storage arrangements and medication records were viewed. Medication administration record charts showed some blank spaces where it is not clear if medication has been given as prescribed. There were also some records that were signed as given, although the medication had not been administered. Some aspects of Standard 9 were not assessed at this inspection as the manager was on leave - this includes the medication policy which was not seen on this occasion. NORTHCOURT LODGE H51-H01-S11034-Northcourt Lodge-V235266280705-Stage 4.doc Version 1.40 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 standard(s) 12,14 and 15 Service users daily life matches their expectations and needs. EVIDENCE: These standards were partially inspected. Service users informed the inspector that their choices of how they wished to receive their care are adhered too and that the staff are very flexible to when changes in the planned care, occur. The social activities available were not reviewed fully but service users commented a variety of these included playing board and card games. Staff were seen to be assisting some service users to do this whist the inspection visit was taking place. The home supports service users to personalise their bedrooms with items of their choice and have visitors as and when they wish. The service users gave their views of the meals and menu inclusive of “well prepared, although repetitive at times and did not offer sufficient fresh fruit” and “home cooked”. Service users choices for meals or preferences are recorded and kept in the kitchen. NORTHCOURT LODGE H51-H01-S11034-Northcourt Lodge-V235266280705-Stage 4.doc Version 1.40 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 standard(s) These standards were not inspected. EVIDENCE: As above. NORTHCOURT LODGE H51-H01-S11034-Northcourt Lodge-V235266280705-Stage 4.doc Version 1.40 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 standard(s) 19,20,21,22,25 and 26 The service users are not fully protected by a safe environment and practices in place in the home. EVIDENCE: The homes recent refurbishment and development programme has given greater scope to the service provision and now has bathroom and bedrooms with en-suite facilities in a new extension to the rear of the property. However, the home has not ensured that the building debris has been removed from the external garden areas and that minor deficits in fixtures and fittings in the new extension have been rectified. The service users are currently unable to use the grounds or gardens safely as the lawns and pathways have not been maintained. The home provides dining, lounge and a small quiet areas for communal spaces for the service users to use. The lighting and furniture are domestic in character. A recent Occupational Therapist assessment has highlighted that some seating and the arrangement of seating may not be appropriate to meet NORTHCOURT LODGE H51-H01-S11034-Northcourt Lodge-V235266280705-Stage 4.doc Version 1.40 Page 13 the needs of the some of the individual service users. Lighting in these areas has also been identified in order for service users to read whilst in the communal areas. The home has 2 assisted bathrooms for 22 residents and 8 rooms with en-suite facilities consisting of hand basin and toilet only. The assisted bathrooms are not totally suitable for service users with minimal physical ability or those require a greater level of care. The home does not have any sluicing facilities. The Occupational Therapist has made several recommendations to be carried out by the home in order to ensure that suitable adaptations and equipment are in place to support service users and prospective service users in the home. These are inclusive of handrails at the appropriate height, ramps, bathroom hoists, hoists and ensuring that adequate storage facilities for equipment are made. Call bells are fitted to all service users rooms, bathrooms and toilets. The homes Statement of Purpose states that hairdressing facilities are available but on review by the inspector, service users and staff are put at risk through the lack of an adjustable specialist sink and the storage of furniture and equipment. The home has not ensured that all service users are protected from hot water surfaces both in their rooms and in the communal areas inclusive of bathrooms as many radiators had no apparent method of guaranteed low temperature control. The radiator in the bathroom on the ground floor was extremely hot to touch and was not guarded and an immediate requirement was made for this to be rectified by the home. The home appears to be kept clean in parts and there are some systems in place for the control of infection. Liquid soap, paper towels and a yellow bag system are made available for staff and service users to use. The laundry area is in the process of being updated, however, the floor surface is not impermeable and loose carpets were laid unsecured on the floor. The home will need to ensure that the washing machines comply to the requirements of temperature and sluicing functions necessary. Not all personal toiletries from previous occupants had been removed from the vacant rooms. NORTHCOURT LODGE H51-H01-S11034-Northcourt Lodge-V235266280705-Stage 4.doc Version 1.40 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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) Not assessed during this inspection. EVIDENCE: As above. NORTHCOURT LODGE H51-H01-S11034-Northcourt Lodge-V235266280705-Stage 4.doc Version 1.40 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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) 33 and 38 The home does not have a full programme of quality assurance. Service users are not fully safeguarded by the homes service provision or safe working practices. EVIDENCE: These standards were partially inspected. The home has some processes in place for consultation with the service users however the proprietor acknowledge that these needed to be expanded further inclusive of recording methods and auditing the physical environment. It was evident on a review of the home and a discussion with the staff that the welfare of service users and staff were compromised by some of the practices occurring in the home. These were incorrect storage of prepared food (not labelled with date when opened or prepared) and personal toiletries left in communal bathrooms and toilets. Other concerns that the safety measures are NORTHCOURT LODGE H51-H01-S11034-Northcourt Lodge-V235266280705-Stage 4.doc Version 1.40 Page 16 not in place in regard to COSHH regulations as staff appeared to be unaware of the regulations as information was not readily on display and cleaning solutions were being left unsecured in the bathrooms, toilets, kitchen, laundry and service users bedrooms. An immediate requirement was made. The home has not ensured that care has been taken in regard to the safety of electrical equipment as cabling was seen to be training across bedroom floors (Rm 11), under a commode (Rm 4) and inappropriate use of electrical socket adapters at floor level (Rm 20). A fuse box on the top floor of the home had ‘open wiring’ exposed that was accessible to people passing by. Immediate requirements were made in order to ensure that service users and staff are not put at risk. Procedures and equipment for fire safety were not in place as staff and service users were seen to be utilising furniture and other objects to hold open fire doors. An immediate requirement was made. NORTHCOURT LODGE H51-H01-S11034-Northcourt Lodge-V235266280705-Stage 4.doc Version 1.40 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 3 COMPLAINTS AND PROTECTION 2 1 1 2 x x 1 1 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 Standard No 16 17 18 Score x x x x x 2 x x x x 1 NORTHCOURT LODGE H51-H01-S11034-Northcourt Lodge-V235266280705-Stage 4.doc Version 1.40 Page 18 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. Standard 9 19 21.9 and 26.6 Regulation 13.2 23 23 Requirement That clear and accurate records are kept of all medication administered to residents. That the external areas of the home are made accesible and safe for service users to use. That suitable sluicing and appropriate washing facilities are available for the disposal and management of foul laundry and clinical waste. That the home implement the recommendations made in the recent Occupational Therapists assessment - July 2005. That the home remove the stored equipement and make safe the area used for hairdressing and ensure that the facilities are suitable for the service users needs. A risk assessment must be carried out for the use of this area. The radiator in the ground floor bathroom is made safe to ensure that it has a low temperature surface. The laundry floor has a impermeable surface. That personal toiletries are not kept in the communal bathrooms H51-H01-S11034-Northcourt Lodge-V235266280705-Stage 4.doc Timescale for action 08/08/05 28/08/05 16/09/05 4. 20,22 23 16/09/05 5. 22 13 26/08/05 6. 25 13 Immediate 7. 8. 26 26 13 13 16/09/05 Immediate Page 19 NORTHCOURT LODGE Version 1.40 and toilets. 9. 10. 11. 24 38 38 33 13 23 That a full quality assurrance process is implemented. That prepared food is suitabled stored and labelled in the fridge. That suitable strategies for fire protection, inclusive of repair to fire door top of the stairway and fire door holders are put inplace. Electical cabling and power sockets are made safe in roms 2,4 and 11. The electrical wire from the fuse box in the corridor on the top floor are made safe. That the home ensures that cleaning fluids are kept in accordance to COSHH . 31/03/05 29/08/05 Immediate & 19/08/05 Immediate Immediate Immediate 12. 13. 14. 38 38 38 23 23 23 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 Good Practice Recommendations NORTHCOURT LODGE H51-H01-S11034-Northcourt Lodge-V235266280705-Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection 2nd Floor, 1015 Arlington Business Park Theale Berks RG7 4SA 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. 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