Inspection on 09/08/05 for Plumstead Lodge

This inspection was carried out on 9th August 2005.

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

Plumstead Lodge 18/12/06

Plumstead Lodge 12/01/06

Plumstead Lodge 23/02/05

Plumstead Lodge 14/09/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Plumstead Lodge 82 - 84 Plumstead Common Plumstead London SE17 3RD Lead Inspector Pauline Lambe Unannounced 9 August 2005 00:00 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. Plumstead Lodge G51G01s6856PlumsteadLodge.v231964.12.8.2005stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Plumstead Lodge Address 82 - 84 Plumstead Common Plumstead London SE18 3RD 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) 020 8854 8255 020 8854 5068 Kent Community Housing Trust Anna Maria Renner CRH 53 Category(ies) of OP 52 registration, with number MD 1 of places Plumstead Lodge G51G01s6856PlumsteadLodge.v231964.12.8.2005stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 Service user in category MD can be accomodated at the home for the period that the named service user is resident at the home. Date of last inspection 23rd February 2005 Brief Description of the Service: Plumstead Lodge is a registered care home providing care and accommodation for 53 older people. The registered provider is Kent Community Housing Trust. The home is a large two storey building located on the busy Plumstead Common Road. It is close to local shops and bus routes. Resident accommodation includes fifty three single bedrooms, adequate communal, bathing and toilet facilities. The home has two passenger lifts enabling residents to access all areas of the home. Every effort is made to maintain a homely atmosphere in the home. Three sides of the building have well maintained garden areas accessible to service users. The home has no parking space, however parking is easily available in the side roads close to the home. Plumstead Lodge G51G01s6856PlumsteadLodge.v231964.12.8.2005stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 7 hours. The Commission last inspected the service on 23rd February 2005. The manager was in charge of the home. Forty five residents were in residence and one resident was in hospital. During the inspection time was spent talking to residents, relatives, management and members of staff. It included a tour of the premises, inspection of care plans, safety systems and records kept as required by regulation. What the service does well: What has improved since the last inspection? What they could do better: The environment looked tired and a number of carpets were worn and stained. Corridors were in need of repair, redecoration and would benefit from having new carpets. To assist with this the provider must prepare a maintenance programme to include actions to taken with timescales for the start and completion of work identified. Plumstead Lodge G51G01s6856PlumsteadLodge.v231964.12.8.2005stage4.doc Version 1.30 Page 6 Care plans must be prepared to show how all resident’s identified care needs will be met. A system must be in place to ensure routine maintenance issues are addressed when the maintenance technician is on holiday. For example the fire alarm must be tested weekly and a check done on window restrictors. 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. Plumstead Lodge G51G01s6856PlumsteadLodge.v231964.12.8.2005stage4.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 Plumstead Lodge G51G01s6856PlumsteadLodge.v231964.12.8.2005stage4.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) 1,3,4 and 5. Standard 6 did not apply to the home. The home provided adequate information about the service and residents were welcome to visit the home prior to admission. Residents were admitted based on an assessment of need and confirmation that the home could meet those needs. EVIDENCE: Residents had access to a statement of purpose and service user guide. Prior to admission the home completed an assessment of need for residents and obtained a care manager assessment. These formed the basis of the individual care plans. Residents received written confirmation that based on assessment the home could meet their needs at the time of admission. Residents and relatives were welcomed and encouraged to visit the home prior to admission. Some residents and relatives seen confirmed this happened. Plumstead Lodge G51G01s6856PlumsteadLodge.v231964.12.8.2005stage4.doc Version 1.30 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) 7,8,9 and 10. Care plans were prepared but some required more detail to show how assessed needs were to be met. Residents had access to medical services as needed and medications were well managed. From observation and comments made by residents they were treated with dignity and respect. EVIDENCE: Although care planning continued to improve some records seen did not have care plans in place to show how all assessed needs were to be met. For example a resident at risk of developing pressure sores did not have a care plan to show how the risk would be managed. Another care plan did not reflect how the residents personal hygiene needs were to be met. Residents were supported to access medical and NHS services as needed. Medications were well managed and no errors were found in the residents medication records checked. Staff worked with the GP to ensure all residents had their medication reviewed. Residents who spoke to the inspector said they were treated with respect. Residents made comments like ‘staff are very kind’ and ‘staff are pretty good’. A resident was celebrating a birthday in the visitors lounge with a number of their relatives and all were having an enjoyable time in privacy. Requirement 1. Plumstead Lodge G51G01s6856PlumsteadLodge.v231964.12.8.2005stage4.doc Version 1.30 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) 12,13,14 and 15. Residents indicated they were satisfied with the service provided and enjoyed regular contact with family and friends. Several residents said they enjoyed their meals and were involved in decisions made about their lives. EVIDENCE: The home had an activity programme and employed designated activity organisers. Residents who spoke to the inspector said they had enough activities provided and could choose whether to participate in these or not. In the care plans seen there was little evidence to show that the residents had participated in activities. The home had an open visiting policy and relatives seen said they were made feel welcome when visiting the home. Several residents and relatives said they were satisfied with the meals provided. Lunch was observed being served. Staff were attentive to residents needs, offered assistance where needed and a choice of meal was provided. A number of residents indicated they enjoyed their meal and confirmed they got the meal of their choice. The kitchen looked clean and tidy but was not inspected on this occasion. Recommendation 1. Plumstead Lodge G51G01s6856PlumsteadLodge.v231964.12.8.2005stage4.doc Version 1.30 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) 16 and 18. Adequate procedures were in place to deal with and record complaints and to ensure residents were protected. Residents and relatives seen said issues raised with management were addressed. EVIDENCE: The home had policies and procedures in relation to the management of complaints and adult protection. Residents and relatives seen said they would feel comfortable discussing concerns they had with staff or management. Records were kept of complaints made about the service. Since the last inspection the home received four complaints and four compliments. The complaints were investigated appropriately and all were substantiated. No complaints about the service had been referred to the Commission since the last inspection. Staff who spoke to the inspector displayed an understanding of adult protection and how they would handle such an incident. Plumstead Lodge G51G01s6856PlumsteadLodge.v231964.12.8.2005stage4.doc Version 1.30 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 to 26. The environment was clean and tidy however the décor in some parts of the home was looking tired and in need of upgrading. Residents seen said they were satisfied with their bedrooms. Equipment and bathing facilities provided were suited to meeting the needs of the current residents. EVIDENCE: The home provided the same communal space as at 31st March 2002. The home had fifty-three single rooms with adequate bathing and toilet facilities to meet the residents’ needs. Equipment provided included portable hoists, assisted baths, grab rails, two passenger lifts and wheelchairs. Records seen showed equipment was maintained regularly. Four bedrooms were assessed against the standards. Some bedrooms were nicely personalised and others were quite bare. Radiators and hot pipes had protective covers fitted and lighting was domestic in character. Plumstead Lodge G51G01s6856PlumsteadLodge.v231964.12.8.2005stage4.doc Version 1.30 Page 13 The home was generally clean and tidy and the laundry facilities were adequate but the area needed repainting. Staff had access to protective clothing and hand washing facilities were provided where waste was handled. The home did not have a maintenance programme for the renewal of fabric and decoration and the following maintenance issues were identified: Several of the towels provided were faded and worn out and must be audited and replaced as needed. The laundry room was not a very welcoming environment to work in. The room needed repainting and the floor covering was damaged and no longer impermeable in places. This must be repaired or replaced. In WC 19 the restrictor had been removed and could pose a risk to residents. Bathroom 53 was used to store items such as unwanted furniture. The maintenance technician agreed to clear this room and make it accessible to residents. The corridor carpet outside WC 67 was stained and must be kept clean. Issues identified in bedrooms were: in room 9 the carpet was stained, in room 5 the over bed light was not working, in room 56 the border was torn off the wall paper and in room 29 the resident had a number of tools that could pose a risk to them or others. All of the above was brought to the attention of the manager. The corridors were generally tired with walls, bedroom and lounge doors and doorframes required repair and redecoration. The inspector was told that the maintenance technician was redecorating the corridors but the work was slow to progress as he was doing this work alone. Requirements 2,3 and 4. Plumstead Lodge G51G01s6856PlumsteadLodge.v231964.12.8.2005stage4.doc Version 1.30 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) 27 and 30 The manager confirmed that the home continued to maintain the staffing levels agreed prior to April 2002. The home benefited from having a stable staff team who received relevant training and supervision. EVIDENCE: Management, residents, relatives and staff did not have any concerns about the staffing levels. The manager said that the staffing hours provided were adequate to meet the needs of the current residents. The home was fully staffed and one new care assistant had been employed since the last inspection. The staff team comprised of a full time manager, assistant officers, team leaders, care assistants, domestic and ancillary staff. Since the last inspection staff had access to training on fire safety, infection control, adult protection and most of the staff had NVQ 2 in care. Team leaders were being supported to obtain NVQ3. Systems were in place to provide regular staff supervision. Plumstead Lodge G51G01s6856PlumsteadLodge.v231964.12.8.2005stage4.doc Version 1.30 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) 31,33,37 and 38. The manager presented as committed to maintaining and improving standards in the home. Residents presented as relaxed and comfortable and having a sense of ownership in the home. Records seen showed attention was given to providing a safe environment. EVIDENCE: The manager was registered with the Commission and accepted feedback from the inspection positively. The home had a recognised quality assurance system in place and resident meetings were held regularly. The manager held resident meetings in small groups to enable all residents to have time to voice their opinions/suggestions on the service. Records were kept as required by regulation and those seen were well maintained and up to date. Plumstead Lodge G51G01s6856PlumsteadLodge.v231964.12.8.2005stage4.doc Version 1.30 Page 16 Safety records seen were well maintained and showed routine servicing and maintenance was carried out. However while the maintenance technician was on holiday the weekly fire alarm tests had not been done. The restrictor had been removed from the window in WC 19. These issues were brought to the attention of the maintenance technician and the home manager Requirements 5 and 6. Plumstead Lodge G51G01s6856PlumsteadLodge.v231964.12.8.2005stage4.doc Version 1.30 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 3 x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 2 3 3 2 2 3 2 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 4 x 3 3 x 3 x x x 3 2 Plumstead Lodge G51G01s6856PlumsteadLodge.v231964.12.8.2005stage4.doc Version 1.30 Page 18 No 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 7 Regulation 15 Requirement The Registered Person must ensure each resident has a written care plan showing how assessed needs will be met in respect of health and welfare. All assesed care needs must be supported by a care plan showing how the need will be met. Residents assessed as being at risk of developing pressure ulcers must have care plans prepared to show how the risk will be managed. The Registered Person must ensure the premises are maintained in a good state of repair. A maintenance programme must be provided with start and end dates for renewal of fabric and redecoration of the home in particular the corridor areas. The Registered Person must ensure the maintenance issues listed under the environmental standards are fully addressed. The Registered Person must ensure any risk to the health and welfare of residents is identified and as far as possible Timescale for action 30th September 2005 2. 19 and 20 23 30th September 2005 3. 23 and 25 23 30th September 2005 16th September 2005 Page 19 4. 24 13 Plumstead Lodge G51G01s6856PlumsteadLodge.v231964.12.8.2005stage4.doc Version 1.30 5. 38 23 6. 38 13 eliminated. The tools kept in bedroom 29 must be safely stored so that they do not pose a risk to residents or others in the home. The Registered Person must take precautions against the risk of fire. The fire alarm system must be tested weekly and records kept. The Registered Person must ensure any risk to the health and welfare of residents is identified and as far as possible eliminated. All windows above ground floor level must have restricted openings. Staff must nor remove restrictors fitted to these windows. 16th September 2005 16th September 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. Refer to Standard 12 Good Practice Recommendations The Registered Person should ensure records are kept to show what activities individual residents enjoyed. The homes record of important dates should be properly completed if it is to be of any use. Plumstead Lodge G51G01s6856PlumsteadLodge.v231964.12.8.2005stage4.doc Version 1.30 Page 20 Commission for Social Care Inspection Riverhouse 1 Maidstone Road Sidcup Kent DA14 5RH 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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