Inspection on 03/02/06 for St Ives Lodge

This inspection was carried out on 3rd February 2006.

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

St Ives Lodge 06/06/07

St Ives Lodge 06/12/05

St Ives Lodge 18/01/05

St Ives Lodge 26/10/04

St Ives Lodge 06/02/04

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 St Ives Lodge 27 The Drive Chingford London E4 7AJ Lead Inspector Zita McCarry Unannounced Inspection 3rd February 2006 02:00 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 St Ives Lodge DS0000007222.V281168.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 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. St Ives Lodge DS0000007222.V281168.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Ives Lodge Address 27 The Drive Chingford London E4 7AJ 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) 020 8529 7952 Mr James Deary Mrs Catherine Deary Ms Maureen Baron Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places St Ives Lodge DS0000007222.V281168.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home can accommodate one (1) named Service User with a Mental Disorder. 6th December 2005 Date of last inspection Brief Description of the Service: St Ives Lodge is a privately owned residential home for 27 elders providing accommodation and care. The home is one of two homes in the area owned by the organisation. The home has an experienced manager and staff group. The proprietors are very much a part of the day to day running and can be found at one or other of the homes. The home is situated on the edge of Chingford which has a range of shops, and locals amenities. St Ives Lodge DS0000007222.V281168.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is the result of an unannounced inspection of St Ives Lodge in early February 2006. The inspector read records pertaining to the running of the home and care files about the care delivered to service users. The inspector also spoke with service users and staff and had to opportunity to observe the activity within the home. The inspector would like to thank service users and staff for their assistance in the inspection process. What the service does well: What has improved since the last inspection? The service has made some new purchases which will improved the storage and administration of medication. The renewal and replacement of some furniture ensures the home keeps it comfortable and well-maintained appearance. St Ives has reviewed the recording and monitoring of accidents in the home and the improvement was evident. St Ives Lodge DS0000007222.V281168.R01.S.doc Version 5.1 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. St Ives Lodge DS0000007222.V281168.R01.S.doc Version 5.1 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 St Ives Lodge DS0000007222.V281168.R01.S.doc Version 5.1 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 the following standard(s): 2,3,4 The home is good at undertaking detailed assessments prior to admission and can assure service users and relatives before admission that they can meet those needs safely. EVIDENCE: The inspector checked the files of two recently admitted service users. In both cases it was evident that the home had undertaken a detailed assessment of need and identified any possible risks before offering prospective service users a place at the home. The inspector was satisfied that the home’s manager was confident that the staff team had the skills necessary to meet the service users identified needs. All service users have terms and conditions of which they sign and agree to. St Ives Lodge DS0000007222.V281168.R01.S.doc Version 5.1 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 the following standard(s): 7, 8, 9, 10 Service users benefit from living in a home where their care needs are met by a respectful staff team. EVIDENCE: The inspector saw two care plans; both were detailed and described the actions required of staff to meet the identified needs of service users. The inspector tracked an identified risk around service users mobility and was pleased to note that the risk was fully addressed in the service users care plan, where staff were directed to ensure the service user had her Zimmer frame and to continue monitoring her mobility. The district nurse visits the home to administer service users insulin and undertakes any other nursing tasks. At the time of the inspection there was no service user in the home with pressure sore. The home has introduced a new accident recording system and this is a considerable improvement. The inspector checked the homes medication. A new secure portable storage system has been purchased and staff report this is a more efficient means of administering medications safely. The inspector checked the medications St Ives Lodge DS0000007222.V281168.R01.S.doc Version 5.1 Page 10 received into the home and found them to be recorded appropriately. A brief audit of two randomly selected medications was undertaken and checked against the medication administration records. These were found to be in order. All service users the inspector spoke to were keen to tell how well they were treated in the home. Two service users told the inspector that they were treated with respect, and described the staff as “kind and patient”. The inspector observed some very supportive and sensitive care being offered to service users. St Ives Lodge DS0000007222.V281168.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 The service is very good at identifying and addressing the individual preferences of service users in respect of their food and activities. EVIDENCE: The home continues to offer service users a wide variety of social and leisure activities that suit their individual needs. These range for armchair aerobics to pub lunches. In relation to activities one service user told the inspector “it all goes on but sometimes I choose to read my newspaper instead”. There are a variety of spaces in the home in which service users can receive visitors, there is no restriction on visiting times and relatives are welcomed into the home. Service users lunch was evidently a relaxed social occasion, when some service users choose to have wine with their meal. One service user who described herself as vegetarian told the inspector that her choices are always accommodated and that staff also provide her with her preferred blend to tea to drink. The inspector met with the kitchen staff team of which has been increased. The cook evidently knew exactly what individual service users preferences were. Menus offered choice and appeared nutritious and wholesome. St Ives Lodge DS0000007222.V281168.R01.S.doc Version 5.1 Page 12 St Ives Lodge DS0000007222.V281168.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 The service has all the procedures in place to guide staff in the event of a complaint or concern about adult protection. EVIDENCE: There is no record of any complaints made to the service since the last inspection. One service user the inspector spoke with said she had “absolutely no” complaints to make about the home but would speak to either the manager or one of the proprietors if she had. The complaints procedure is clearly visible and accessible in the home. The home has had no adult protection issues identified and staff have received training in this. The home has a procedure to guide staff in the appropriate action to take in the event of suspicion or actual abuse. St Ives Lodge DS0000007222.V281168.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 26 Service users live in a well maintained, clean and comfortable environment. EVIDENCE: The home is comfortable and decorated to a high standard; the recent replacement of older armchairs has improved the ambience of the home. Service users recognise the home as comfortable and accessible. The home has two lifts which assist service users access their bedrooms on the first and second floors. It was identified at the inspection that there was a problem with the hot water supply that affected a few service users en suite facilities. The plumbers had been on site for several days trying to identify the cause of the problem. A service user who had a room affected told the inspector that it was no inconvenience to her as staff carried hot water to her. The fault was identified and fixed before the end of the inspection. The home is clean and odour free throughout. St Ives Lodge DS0000007222.V281168.R01.S.doc Version 5.1 Page 15 St Ives Lodge DS0000007222.V281168.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 The home is failing to ensure a robust safe recruitment of staff. EVIDENCE: The home keeps a duty rota recording the staff on duty at any given time. There are four early and three late staff per shift. This appears to be sufficient staff numbers to meet service users needs and provide a lively activity program. The inspector checked the files of two recently appointed members of staff. It was evident on both files there were application forms, which detailed appropriate employment histories, and photographic identification. However the robustness of the services recruitment was undermined in two areas. Firstly in one file the POVA first clearance did not come through until almost one month after the worker had taken up post. On the second file there was only one written reference. There was a record of a reference taken over the phone what there was no indication on that form who provided the verbal reference. Therefore there was sufficient evidence that staff were appointed to work in the home without full and satisfactory pre employment checks. St Ives Lodge DS0000007222.V281168.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 36, 38 Service users benefit from living in a well managed home. EVIDENCE: The registered manager holds the necessary management qualifications; additionally she is qualified to train staff in her areas of expertise. The manager has extensive knowledge and experience in the care of older people and continues to demonstrate her competence in managing the service. The manager and proprietors have established a service that encourages feedback from service users and relatives. The value of the senior team is recognised by service users. Of the manager one service user told the inspector “I couldn’t possible be happier with anyone else in charge”. The inspector randomly selected a staff member’s file to test the supervision processes in the home. It was evident that the member of staff was having St Ives Lodge DS0000007222.V281168.R01.S.doc Version 5.1 Page 18 relevant supervision that reflected on her practice. Additionally there were discussions around procedures, care plans and support for individual service users. The home has employed a consultancy to advise on health and safety matters within the home. The inspector read the most recent report one of the recommendations is that the home undertakes a full evacuation of the service. The manager is concerned about the possible risks this may present for service users and the anxiety it would cause. The inspector concurs with this view. The manager needs to consult with the fire authority before undertaking a full evacuation of the home. St Ives Lodge DS0000007222.V281168.R01.S.doc Version 5.1 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 3 3 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X 3 X X X X 4 STAFFING Standard No Score 27 3 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 3 X X X 3 X 3 St Ives Lodge DS0000007222.V281168.R01.S.doc Version 5.1 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. 1. Standard OP27 Regulation 19 Requirement The registered manager must ensure all pre-employment checks, as detailed in Schedule 2 of the CHR 2001, are in place and satisfactory before staff are offered employment. Timescale for action 01/04/06 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 St Ives Lodge DS0000007222.V281168.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection East London Area Office Gredley House 1-11 Broadway Stratford London E15 4BQ 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 St Ives Lodge DS0000007222.V281168.R01.S.doc Version 5.1 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. 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. 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