Inspection on 23/12/05 for Russell Hill Lodge

This inspection was carried out on 23rd December 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Russell Hill Lodge 15/04/08

Russell Hill Lodge 20/09/07

Russell Hill Lodge 18/04/06

Russell Hill Lodge 15/08/05

Russell Hill Lodge 13/01/05

Russell Hill Lodge 12/08/04

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

CARE HOME ADULTS 18-65 Russell Hill Lodge 39 Russell Hill Road Purley Surrey CR8 2LD Lead Inspector Margaret Lynes Unannounced Inspection 23rd December 2005 2:55pm Russell Hill Lodge DS0000025833.V275000.R01.S.doc Version 5.1 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 Russell Hill Lodge DS0000025833.V275000.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. 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. Russell Hill Lodge DS0000025833.V275000.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Russell Hill Lodge Address 39 Russell Hill Road Purley Surrey CR8 2LD 020 8668 3212 020 8668 3212 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) Laurel Residential Homes Limited Care Home 18 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (18) of places Russell Hill Lodge DS0000025833.V275000.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th August 2005 Brief Description of the Service: Russell Hill Lodge is registered to provide care to up to 18 adults who have past or present mental health problems. The home is situated close to Purley town centre and therefore well placed for access to the towns amenities and transport. The house is a large detached traditional brick built building. It has 18 single rooms, a lounge, dining area and conservatory. The latter area is the designated smoking room. One of the single bedrooms has en - suite facilities, including bathing and catering facilities. Russell Hill Lodge DS0000025833.V275000.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of this visit was to determine if the home had taken action to meet the four requirements that were made following the last inspection visit. Of these aforementioned four requirements, the home has partially met two, one remains unmet, while it was not possible to assess the remaining requirement. Two new requirements have been made. Efforts need to be made to meet these requirements as in doing so the home will improve the overall quality of the service being provided, and improve the well-being of the service users. What the service does well: What has improved since the last inspection? What they could do better: Further action is needed on the aforementioned quality assurance system and the pre-admission assessments. The registered person must also ensure that only service users for the category the home is registered are admitted (unless a variation has been agreed by CSCI, prior to admission). The proprietors also need to take urgent steps to comply with the required monthly visits to the home and the production of a report of each of these visits. A new requirement has been made re the medication administration records. This is disappointing, as after previous criticism the recording had improved. A second new requirement has been made with regard to fire safety and the need to ensure that all recommendations made by the LFEPA are followed. Russell Hill Lodge DS0000025833.V275000.R01.S.doc Version 5.1 Page 6 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. Russell Hill Lodge DS0000025833.V275000.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Russell Hill Lodge DS0000025833.V275000.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 The Inspector was still not fully satisfied that adequate pre-admission assessments were being made. This means that service users cannot be assured that the home has taken into account their individual needs, and that it can meet them; and that the staff in the home will not be as familiar as they could be with new service users, or have a full understanding of what specific service they will need to provide. EVIDENCE: The files of the two newest service users were inspected. While it is acknowledged that one transferred back to Russell Hill after a stay in another of the proprietors’ homes, it was surprising to find that there was little documentation to indicate why this move had taken place. While a preadmission assessment had been carried out on the other new resident, it was of concern that there was clear indication in the supporting documentation that this client’ s diagnoses did not wholly fit within the registration category of the home. In such circumstances the proprietors should have applied for a variation, and they are hereby requested to provide an explanation of this admission to the CSCI. The Commission will then consider what action it may need to take. Russell Hill Lodge DS0000025833.V275000.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not assessed on this visit. EVIDENCE: Russell Hill Lodge DS0000025833.V275000.R01.S.doc Version 5.1 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not assessed on this visit. EVIDENCE: Russell Hill Lodge DS0000025833.V275000.R01.S.doc Version 5.1 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 A number of errors were noted in the medication records. This is unacceptable, as any mistakes made in giving out medication can have serious consequences for the service users. EVIDENCE: It was disappointing to find a number of errors in the medication charts. Concerns had been expressed to the manager on previous visits, and improvements had been made. Action must be taken to stop this deterioration and, if needed, further training provided for staff. Russell Hill Lodge DS0000025833.V275000.R01.S.doc Version 5.1 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not assessed on this visit. EVIDENCE: Russell Hill Lodge DS0000025833.V275000.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not assessed on this visit. EVIDENCE: Russell Hill Lodge DS0000025833.V275000.R01.S.doc Version 5.1 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 and 35 As the manager was not present for this inspection, it was not possible to gain access to the staff files. Compliance with the requirements regarding staff induction and training will, therefore, be assessed at a future visit. EVIDENCE: Russell Hill Lodge DS0000025833.V275000.R01.S.doc Version 5.1 Page 15 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 A new manager has recently been appointed. Once he has had a settling in period, it is to be hoped that he will continue the good work that was being done in the home, and also take action to meet the outstanding requirements. As the manager had only just taken up his post, the Inspector deemed it unreasonable to give judgement on his suitability at this early stage. The Inspector was still not fully satisfied that the home was being run in the best interests of the service users as the quality assurance system still needed further development. The Inspector felt that in the area of fire safety, the home was not being maintained to an appropriate level of safety, thus potentially exposing service users to unnecessary risk. EVIDENCE: The new manager has only been in post for a matter of weeks. His leadership and management skills will thus be assessed at later inspection visits. Russell Hill Lodge DS0000025833.V275000.R01.S.doc Version 5.1 Page 16 While considerable improvement had been made to the quality assurance system, and it now contained evidence of, for example, service user surveys, monthly room checks, and environmental health and safety maintenance, it did not have any audits of aspects of the service such as keyworking, care plans, rehabilitation programmes or activities. A visit to the home in September by an officer from the London Fire and Emergency Planning Authority had resulted in a number of recommendations being made. While it could be evidenced that most of these recommendations had been met, the Inspector could not find the home’s fire risk assessment. A requirement has been made to this effect. It was noted in the report of a recent fire detection system/emergency lighting maintenance visit that the emergency lights in the bedrooms were no longer in good working order and should be replaced. It is presumed that the proprietors will arrange for any necessary work to be carried out without undue delay. Russell Hill Lodge DS0000025833.V275000.R01.S.doc Version 5.1 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 X X X 2 X X 2 X Russell Hill Lodge DS0000025833.V275000.R01.S.doc Version 5.1 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. Standard YA39 Regulation 24 Requirement An appropriate quality assurance system must be implemented in the home, which seeks service users views and measures the success of the home in meeting the aims and objectives laid out in the Statement of Purpose. The previously set timescale has not been fully met. The manager must ensure that more detail recording is made of pre-admission assessments. The previously set timescale has not been fully met. The registered person must also ensure that only service users for the category the home is registered are admitted (unless a variation has been agreed by CSCI, prior to admission). Medication records must be accurately maintained at all times. Staff must refrain from using Tippex on these charts. The manager must ensure that all new staff receive a suitable induction and that this is recorded. Unable to assess on this visit. The proprietors must ensure that DS0000025833.V275000.R01.S.doc Timescale for action 28/02/06 2. YA2 14 23/12/05 3. YA20 13 23/12/05 4. YA35 18 23/12/05 5. YA39 26 23/12/05 Page 19 Russell Hill Lodge Version 5.1 6. YA42 23 they visit the home on a monthly basis and write a report of that visit. A copy of the report must be sent to the CSCI (local) office. The previously set timescale has not been met. The registered person must 31/01/06 ensure that action is taken to meet all of the requirements of the LFEPA. 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 Russell Hill Lodge DS0000025833.V275000.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Russell Hill Lodge DS0000025833.V275000.R01.S.doc Version 5.1 Page 21 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!