Inspection on 06/12/05 for St Ives Lodge

This inspection was carried out on 6th December 2005.

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 03/02/06

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 6th December 2005 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 St Ives Lodge DS0000007222.V266849.R01.S.doc Version 5.0 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.V266849.R01.S.doc Version 5.0 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.V266849.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home can accommodate one (1) named Service User with a Mental Disorder. 18th January 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.V266849.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is report is the result of an unannounced inspection of St Ives Lodge in a morning in early December. 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. As the manager was on training there was no access to the staff files, so the inspector was unable to neither test the recruitment procedures within the home nor see the certificates for staff training. These will be tested at the next inspection. 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 care plans have been further developed and these provide good guidance on supporting individual service users needs. St Ives have extended how they seek feedback form service users and relatives, comments are sought on areas such as staff competence, facilities, hygiene, menus, accidents and complaints. St Ives Lodge DS0000007222.V266849.R01.S.doc Version 5.0 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.V266849.R01.S.doc Version 5.0 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.V266849.R01.S.doc Version 5.0 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, 5 The senior team at St Ives are skilled at assessing and make safe admissions to the home. Prospective service users and their families are well supported during the admission process. EVIDENCE: The inspector reviewed the file of a recently admitted service user. It was evident that the home had undertaken a full assessment and had obtained sufficient information to make the decision they could provide care for the prospective service user in St Ives Lodge. The service user had the opportunity to visit the service beforehand to have a meal, meet other service users and staff. The inspector also noted on file that St Ives and the service user had agreed term and conditions of residency at the point of admission. Another service user described to the inspector the support St Ives offered her and her family when she was considering admission. St Ives Lodge DS0000007222.V266849.R01.S.doc Version 5.0 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 St Ives has detailed written arrangements that describe how it meets the needs of individual service users. The service does not consistently record the details of accidents correctly. EVIDENCE: The inspector reviewed three service users care files and was impressed with the level of detail in the care planning. The care plans have been further developed and the improvement was noted. Staff are given very clear guidelines on the action they must undertake to meet specific needs. The care plans are underpinned by two risk assessments, one for the moving and handling of service users which instructs staff on the actions required of them to move service users safely. The second risk assessment is generic and addresses individual risks for service users. There was good evidence that the manager of the home had effectively consulted with the family advocating for a service user and district nurses before putting cot sides on a service users bed to prevent further accidents. St Ives Lodge DS0000007222.V266849.R01.S.doc Version 5.0 Page 10 On reading an entry on one service users care notes it recorded she had sustained an injury, the inspector tracked the accident but noted that no accident form had been completed nor was information on the care notes in respect of the details of the accident, or follow up action taken. The home uses the blister pack system of medication. All medications are stored securely. The inspector randomly selected two service users medication that was not blister packed and checked the amount of medication held, dispensed and compared this to the medication recorded as dispensed. All medication was found to be correct and the records balanced. The inspector observed staff speaking with service users and noted the relaxed respectful manner of their approach. One service user told the inspector that both herself and less well orientated service users are all addressed in an equally respectful manner she added she praised the staff for their consistency in this saying “I don’t know how they do it day after day”. St Ives Lodge DS0000007222.V266849.R01.S.doc Version 5.0 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, 15 The home has an excellent activity schedule which offers service users a variety of leisure and social interests. St Ives is good at welcoming visitors and relatives. EVIDENCE: Two service users told the inspector that they have regular visitors to the home and that the staff welcome them with offers of tea. One service user told the inspector she always receives her visitors in the privacy of her room but that they can make use of any space such as the conservatory or quiet lounge. The home offers service users an excellent range of activities and the resources to deliver them. Activities are planned on a monthly basis. Examples of activities offered are armchair aerobics, prize bingo, pub lunches, massage, art and beauty sessions. There was also good evidence that service user feedback on activities was actively sought and their suggestions acted upon. One service user told the inspector that she most enjoyed the quiz, which was chaired a couple of times a month by a local librarian. She said this had recently come to an end with the retirement of the librarian. The home menus were inspected and on the day of the inspection the main course and alternative were as the plan recorded. Feedback from service users St Ives Lodge DS0000007222.V266849.R01.S.doc Version 5.0 Page 12 on the quality of food was “quite nice” and “very good”. Meals were observed to be leisurely and sociable. St Ives Lodge DS0000007222.V266849.R01.S.doc Version 5.0 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 users and families have an accessible complaints procedure and are reminded of the process. EVIDENCE: There have been no complaints received in the last year. The home has a clear procedure advising service users, advocates and relatives on how to lodge a concern or complaint. One service user told the inspector that she had no cause for complaint but knew exactly what action to take if she had. There was evidence for recent review notes that the proprietors revisited the complaints procedure with service users and relatives and reminded them of the process if they had any concerns. There have been no adult protection issues in the service, but again there are clear guidelines for staff. Most staff have undertaken training some time ago but the inspector saw evidence of further adult protection scheduled for 11th January 2006. St Ives Lodge DS0000007222.V266849.R01.S.doc Version 5.0 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, 23, 24, 26 St Ives Lodge is a comfortable home decorated and furnished to a high standard, which is well maintained. The home is clean, communal spaces airy and bright and service users bedrooms well personalised and homely. EVIDENCE: St Ives is located in a quiet residential road; close to local shops. It is accessible by wheelchair. The home has a rolling programme of redecoration and refurbishment and this is evident in the fabric of the home. The home has two lifts which access the three levels of the home. Bathrooms are suitable equipped with aids and hoists. All areas of the home accessible by service users have call bell system. Those rooms seen by the inspector were very homely well personalised by family photographs and ornaments. One service user told the inspector that it took some adjusting downsizing her life from living in a spacious flat to one enSt Ives Lodge DS0000007222.V266849.R01.S.doc Version 5.0 Page 15 suite room but she was pleased that she could take her most loved possession with her. The home is clean free from any odours the laundry floor is impermeable and wall surfaces easily cleanable. St Ives Lodge DS0000007222.V266849.R01.S.doc Version 5.0 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): There is sufficient numbers of trained staff on duty to meet the needs of service users. EVIDENCE: On the day of the inspection the home had twenty six service users in residence. Inspection of the rota recorded that there were 4 carers on an early shift and 3 on a late shift. There was no evidence to suggest that these staffing levels were inadequate and the proprietor advised that they are reviewed as service users needs change. Almost 50 of the care staff at the home hold either an NVQ 2 or 3 award and other staff are currently working toward achieving the award. St Ives Lodge DS0000007222.V266849.R01.S.doc Version 5.0 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, 37, 38 The home is well managed, there is effective monitoring in place and the service users and relatives recognised the manager and staff are good at their jobs. EVIDENCE: The registered manager is nearing completion of her RMA she is an experienced manager who has demonstrated her knowledge and skills in the care of older people. The manager regularly updates her own training and ha almost completed a certificated trainers award. Whilst the registered providers are very visible in the home lines of accountability are clear. Service users and relatives recognise that both the manager who is “good at her job” and someone they would go to if necessary. One service user told the inspector that she attends all service user meetings and “wouldn’t miss them for the world”, but she added that she that she would not want to have any St Ives Lodge DS0000007222.V266849.R01.S.doc Version 5.0 Page 18 greater say in the running of the home because “its managed very well as it is!” The home has contracted a consultant to advise on the health and safety aspects of the home and they undertake regular reviews. The inspector saw an up-to-date fire risk assessment, records that the home checks weekly that the fire system is working correctly. There were also certificate of fire alarm and emergency lighting being serviced regularly. St Ives Lodge DS0000007222.V266849.R01.S.doc Version 5.0 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 X 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X 3 3 X 4 STAFFING Standard No Score 27 3 28 3 29 X 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X X X 3 3 St Ives Lodge DS0000007222.V266849.R01.S.doc Version 5.0 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 OP8 Regulation 12 Requirement The registered manager must ensure all accidents are appropriate documented and follow action recorded. Timescale for action 11/02/06 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.V266849.R01.S.doc Version 5.0 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. 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