Inspection on 11/08/05 for St Mary`s Lodge

This inspection was carried out on 11th August 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

St Mary`s Lodge 17/11/09

St Mary`s Lodge 29/09/09

St Mary`s Lodge 01/05/08

St Mary`s Lodge 02/10/07

St Mary`s Lodge 20/11/06

St Mary`s Lodge 02/02/06

St Mary`s Lodge 11/11/04

St Mary`s Lodge 17/05/04

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 Marys Lodge 81-83 Cheam Road Sutton Surrey SM1 2BD Lead Inspector David Pennells Announced 11 August 2005 09:30 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. St Marys Lodge Version 1.10 Page 3 SERVICE INFORMATION Name of service St Marys Lodge Address 81 - 83 Cheam Road, Sutton, Surrey, SM1 2BD 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 8661 6215 020 8643 9133 (residents) 020 8661 6215 Mr Jugdutt Dudhee n/a Care Home 40 Category(ies) of Old Age (20) registration, with number Dementia - over 65 (20) of places St Marys Lodge Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11/11/04 Brief Description of the Service: St Mary’s Lodge is situated within walking distance of Sutton town centre, which provides a wide range of transport links, commercial, shopping, entertainment and recreational facilities. The home is a substantial property created from the joining together of two large Edwardian family houses, with two wings of accommodation to the rear subsequently being added. The accommodation is laid out over three main floors, access to which is provided by a passenger lift and stairs; there are, however, many areas of the home that are only accessible by varying numbers of steps and the two sides of the home at ground level are also separated by a step. The home provides thirty single and five double-occupancy bedrooms. Communal space is generous and homely in character, being provided in a range of varying lounge / dining areas throughout the ground floor The home is registered to provide accommodation and care to 40 older people, 20 of these places now falling within the category of ‘people over 65 with dementia’. This formula was adjusted last year to reflect the number of service users who actually do have a form of dementia: previous to this, the home had only registered ten out of the forty beds to accommodate people with dementia or a related condition. This ‘mix’ continues present a challenge to the home as it supports those who are mentally sound - alongside those service users with failing memory / mental ability. St Marys Lodge Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection visit was announced in advance, with posters being sent to the home to forewarn relatives, service users and staff. The date had been changed from the originally announced date, due to extenuating circumstances. The inspector spent the day from 9.30am to after 5.00pm at the home. The morning was spent with the proprietor / manager - covering documentation and reviewing the pre-inspection questionnaire and outcomes from the previous inspection report. Lunchtime marked the move to spending time with service users at the home; from 12 noon to about 2pm the inspector spent time with the service users, sharing food with five others and wandering around the home unescorted, meeting service users and staff as he went. A tour of the home followed - with the proprietor – before the inspector again spent time with service users (and meeting a relative), this phase of the visit also enabling the assessment of records / care plans and other documentation relating to the care provided. A short period of feedback to the proprietor led to the inspector’s departure as service users settled down to supper. What the service does well: The home provides a welcoming environment for service users – both those with and without dementia – and strives to ensure that a comfortable lifestyle is provided for service users to enjoy. Relatives are clear that they are welcome, that privacy can be afforded, and that they are involved in the decision-making concerning care planning and issues of importance relating to the individual. In almost all cases, the clear message is that the home provides a careful and attentive atmosphere in a friendly environment. Service users also clearly felt comfortable at the home, those with mental capacity having an appreciation of the service provided, and those with dementia generally being clearly at ease in the house, showing little sign of anxiety or apprehension. Premises are kept well ordered and clean; the home has had very few reports of malodour. Communal areas are kept as homely as possible – Mrs Dudhee has a ‘way’ with floral and ornamental decoration - and well decorated. The home, being an existing (Victorian) premises, has its own individuality and character. St Marys Lodge Version 1.10 Page 6 What has improved since the last inspection? What they could do better: Regarding care input, advice is given in this report about ensuring that the intent of the care plan is situated closer to service users day-to day notes / the assessment of their functioning. A requirement that all service users have notes of action to be taken if seriously ill or passing away – ‘Last wishes’ - is repeated. Techniques to ‘get closer’ to service users - through life history work with both the individual and their relatives and friends are recommended. Recommendations about certain care practices observed – including the monitoring of frequency of baths - are listed. On the health & safety front, the checking of hot water outflows must be ensured, whilst concerns about fire break doors being inappropriately held open leads to a requirement to consider electro-magnetic means attached to the fire alarm system. Attention to the prevention of Legionella poisoning – through regular professional checks is required, whilst a review of emergency call points seeks to ensure that these are sited most appropriately in rooms – especially bathrooms and toilets is repeated. The home is also recommended to review the provision of grab rails in toilets and bathrooms – to ensure the safe routes to independence, and the inspection and replacement of ferrules on service users is a basic - but essential element to build into the home’s regular safety precaution checklists. St Marys Lodge Version 1.10 Page 7 With regard to the premises, a clearly thought-through and research-based approach to the décor and signage in the home is required to be universally implemented in order to support and guide particularly the service user group who have dementia. There is also a recommendation that the use of the garden could be increased if the facilities externally were further upgraded. With regard to personnel issues, the checking of references / the proper application of the rules regarding Criminal Record Bureau checks / and ensuring that all required elements of documentation are held per staff member – including fully completed induction records - are emphasised. Staff should also be required to fully sign against all policies & procedures. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Marys Lodge Version 1.10 Page 8 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 St Marys Lodge Version 1.10 Page 9 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) 3 & 6. Service users can rely on needs being full assessed before being admitted to the home, and a care plan being put in place to address identified areas of need thus ensuring appropriate individual care being provided. EVIDENCE: The majority of service users at this home are placed/funded by Local Authorities, consequently at referral the responsibility is on the authority to provide a comprehensive assessment of need including a provisional care plan - which is then developed by the home. The proprietor/ manager stated that comprehensive assessments are not always forthcoming from Care Managers prior to admission of a service user. The proprietor also makes a visit to the prospective client and undertakes his own assessment of all new service users. This information is - if the service user is assessed as suitable - translated over to the ‘Good Care Planning’ booklet used by the home - which provides for a comprehensive assessment of the service user. The Care Planning booklet used by the home provides for a comprehensive induction process to ensure that all necessary risk assessments and areas of need are identified prior to the home The home does not provide intermediate care and therefore standard 6 does not apply to this home. St Marys Lodge Version 1.10 Page 10 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, 10 & 11. Service users needs are fully assessed using a plan of care that then guides staff members to provide an individualised service, including meeting their broad health care needs, the administration of medicines and general social care. A heightened awareness of the detail of care plans by staff would benefit service users through a more consistent approach to the individual. Medication administration is appropriately managed and properly recorded and stored, though the location of district nursing supplies storage could be improved. Service users can generally rely on staff to provide sensitive personal care – though guidance to staff in aspects of dignified management of care is recommended. Certain daily personal care activities need reviewing and monitoring by the management to ensure clear 1:1 personal care services are provided in the privacy of their own rooms (rather than in communal spaces) to maintain service user’s self-esteem and pride. Service users can rely on appropriate care at the point of severe illness / death; though the gathering of details concerning a service user’s or their representative’s “final wishes” in a coherent form on the care plan is still to be worked on. St Marys Lodge Version 1.10 Page 11 EVIDENCE: The examination of the home’s care planning and its inter-linking with daily notes revealed that there was a ‘divide’ between the care plans - as declared in the care plan booklets [currently held in the office filing cabinet] – and the daily Kardex kept in a filing cabinet in the main central lounge – with a smaller (more historic, sometimes) sketch of the basic plan. The inspector’s observations of staff interventions - especially to those with special needs, due to their dementia – were somewhat inconsistent. This does not give the service user any sense of confidence or reality and cannot satisfy staff, as they then have to deal with the consequences of ‘mixed messaging’ by others. The importance of the closer connection of the current care plan to the day-to-day practice and recording by care staff is strongly emphasised. Service users are now signing care plans more regularly. New admissions’ care plans were clearly endorsed by their subjects. The inspector wishes to strongly recommend that the materials used by the district nursing service (although easily accessible and convenient at present to the nurses) are stored in a cupboard or place more appropriate than being left in boxes openly accessible under the sideboard in the lounge – this for infection control and both hygiene and security reasons. Chiropody – which was infrequently provided from the NHS – is now provided to those who require just basic foot care by care staff who have been trained by the chiropodist to undertake this service. The home provides the equipment on the advice of the practitioner. A private chiropodist is also available at the home for a fee of £10 - £15. Medication routines are managed and directed by the proprietor - and it is good to see that the pharmacist has now almost completely provided medication in the (safer) MDS (Monitored Dosage System) arrangement. Medication is easier to dispense and monitor in this new regime, and it will save staff time once fully implemented. The most recent Pharmacy visit to the home (28/07/05) resulted in a satisfactory report. Medication profiles are now also fully in place. During the observational time spent by the inspector in the afternoon, staff members were seen to be assisting service users to the toilet wearing gloves in the communal areas of the home. This approach militates against maintaining both the dignity and privacy of service users. This generalised indiscriminate use of gloves is also a potential cross-infection route. Gloves should only be put on when necessary in the privacy of a toilet / bathroom – and they should be discarded following the offering of personal care to one service user only. St Marys Lodge Version 1.10 Page 12 Another concern of possible reduction of dignity and also possible crossinfection was the storage of shaving equipment in the lounge sideboard; such items were not labelled as belonging to individual service users and a staff member suggested that service users were shaved in the communal lounge. If this practice is undertaken (the inspector did not see this directly) then it should cease and all staff members instructed in guarding the privacy and dignity of each specific service user at the home. The home’s ‘bath book’ – available close to the daily ‘Kardex’ – suggested, through the staff signing the record and writing the service user’s name, that over the past six entire weeks the number of baths undertaken by staff were as follows: 12 / 6 / 8 / 6 / 14 / 8. Clearly for a service providing care to forty service users, the above figures are worrying. The proprietor was requested to closely monitor the frequency of baths - to those who requested / required / expected them – to ensure adequate input from care staff. A testimony from representatives of a recently deceased service user spoke of the quality of care provided by the home to their loved one over two years of residence until they passed away at the home. Certainly the more physically frail service users appeared as well as possible – bearing in mind the great age of some service users (95 ). Eight service users had died at the home in the past twelve months, with just one being admitted to hospital prior to this event. Details (“last wishes”) concerning a service user’s directions should they be taken suddenly seriously ill or pass away were still ‘in process’ of being sought, recorded and confirmed; this task, though difficult, must be pursued to ensure a clear instruction is held in regard to each service user. St Marys Lodge Version 1.10 Page 13 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 & 15. Service users can expect to engage with social and recreational activities suited to their preferences. Spiritual needs are identified and met through contact with local church ministers/congregations. Relatives and friends can expect to be welcomed at the home and service users are encouraged to maintain contacts with links outside the home. Service users can expect to receive a wholesome and nutritious diet provided by the home, with special needs generally recognised and catered for. EVIDENCE: Activities in the home are varied and suited to the varying skills base of the service users. Sing-a-longs, reminiscence, Drawing sessions, Dominoes and Cookery are described by the home as being available. Small trips out into Nonesuch Park and to Sutton or Merton for shopping expeditions are provided, and one service user still attends a Church Club that they previously attended. The inspector strongly recommends the adoption of ‘Life History / Story’ Books – a form of ‘scrap book’ work - relating to each individual service user, enabling them to connect more appropriately to their past and the reality of their personality. This process also provides staff with a way of ‘meeting’ the service user in the fullness of their (sometimes, previous) being – through relating to recognisable roles and skills. ‘Life History / Story’ work also St Marys Lodge Version 1.10 Page 14 encourages the engagement of relatives and friends - who can be great sources of photographs and other historical resources - and of reminiscences and stories relating to the service user. During the observational phase of the inspector’s visit, in one lounge, modern, unrecognisable & incessantly beating ‘pop/ rap’ music being played on the radio; the resulting ambience of the lounge was therefore one of isolation and disengagement – as service users were not able to recognise or enjoy / hum / sing-a-long to this music – which, possibly, was the choice of the staff in that lounge. Spiritual needs of service users are catered for: Holy Communion for Roman Catholics is available every Friday. A local Church has invited the home to send service users to its Harvest festival celebrations in September. The local Methodist Church puts on a monthly ‘in-house Service’ for service users. The proprietor /manager gave the inspector thirty-eight ‘service user questionnaire’ forms, apparently from all individual service users in the home. On closer examination, all forms were completed in the same ink - and all had the same response – i.e. being positive about all the services at the home (38/38), not wishing to become more involved in decision-making in the home (38/38), ands not wishing to speak to the inspector about life at the home (38/38). There was no further comment written on any of the forms. The inspector has never come across a totally unanimous response – particularly from such a large sample of people – and relies, therefore, more strongly on the relatives’ and other stakeholder questionnaire responses (most of which were received independently at the Commission’s office) for feedback about the service. Thirteen relatives, one GP the pharmacist and two care managers returned forms to the Commission, all generally favourable about the service and a number providing positive qualitative comments alongside the ‘tick boxes’. The services were described as: ‘caring’ and ‘attentive’, ‘friendly atmosphere’, ‘all needs met’, ‘very satisfied’, ‘we have a good relationship with the proprietors’. Only one negative response was forthcoming; which the inspector is not able to endorse through his own experience: ‘The home seems smelly.’ The Statement of Purpose has a clear written section concerning the encouragement of visitors (family and friends) to service users. The use of the words “positively encourages” indicates the open attitude of the home; staff members also offer to “help keep essential family and community ties”. One relative seen on the day of the visit commented that they visit frequently and that “I am made very welcome”. The inspector enjoyed a very pleasant lunchtime with five service users in one of the dining rooms. The table was attractively laid, and the food served was interesting, wholesome and very tasty. There was an alternative pudding St Marys Lodge Version 1.10 Page 15 offered at the time – which was taken up by two service users. All service users relished their meal - and there was conversation at the table, adding to the pleasurable, informal atmosphere. One vegetarian was served a meal – which the inspector also had – but, sadly, the service user (who had been at the home for some time) was surprisingly served peas in her meal – which she was clear she does not like - and staff members were also aware of this. Not wishing to make a fuss, this service user spent a lot of her time ‘sorting out’ the disliked from the preferred ingredients. A recent Food Safety and Hygiene inspection visit by the local Environmental Health Officer found the general catering well organised and cleanliness at a satisfactory standard. The inspector, therefore, only quickly checked the kitchen areas and - indeed - found them to be at a good level of organisation and cleanliness. Records are kept of special dietary provision, and all temperature checks (fridges and food temperatures) were consistently kept. St Marys Lodge Version 1.10 Page 16 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. Service users can be confident that the home will deal with complaints appropriately; information about the complaints procedure is readily available to all who may wish to express an opinion about the service. EVIDENCE: The proprietor confirmed in the pre-inspection questionnaire and on the day of the inspection that the home had received no complaints in the past twelve months. The home has a comprehensive complaints procedure, which is included in the home’s Statement of Purpose. The procedure has clear timescales for actioning a complaint and a process for recording such complaints and feeding back to complainants. The relative’s / stakeholder’s questionnaire revealed that the vast majority of the respondents were aware of the home’s complaints procedure; only one stated that they had used this process in the past. St Marys Lodge Version 1.10 Page 17 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, 23, 24, 25 & 26. Service users can expect to live in a clean and well-maintained environment. Those service users with dementia would benefit by increased signage and other aids to promote their independence. Communal lounge and dining facilities are homely, warm and generally comfortable. Communal toilets and bathrooms are suitable to service users, though in larger rooms re-assessment for grab rails / frames around toilets is advised – alongside the required reassessment of the emergency call bell provision. Service users own bedrooms are distinctively different, and offer scope for the personalisation that the home encourages. Bedrooms are both safe and comfortable, meeting the individual’s needs with all basic amenities provided. EVIDENCE: The general condition of the home and the facilities is good; the premises were kept clean and odour-free. St Marys Lodge Version 1.10 Page 18 A number of issues raised in the last report relating to the premises have been actioned. Sadly, the home has lost its handyman – so an ‘instant repair’ to a toilet seat fixing on the day of the inspection was carried out by the proprietor, Mr Dudhee. Safety requirements – such as the covering of a storage heater, the removal of a (poorly situated) old gas fire in one bedroom, the reinstatement of safety chains on some upper floor windows and the cleaning / replacement / installation of extractor fans in a number of different locations had all been addressed. The home has recently redecorated one of the lounges in a distinctive colour the ‘blue room’ – to ‘anchor’ service users in their familiar environment. There continues to be a need to ensure that the house further develops a culture of being well ‘sign-posted’ for service users – both those who are competent and those not so aware – to ensure that (particularly) service users with dementia are as assisted as possible in being oriented in time and place. This should include orientation boards, calendars, clear-faced clocks, directional signage and pictorial representations, universal colour coding, etc. The inspector also noted some unnecessary signs – such as ‘No mobile phones’ – clearly introduced to remind staff not to use them during working time – but now displayed on the walls in lounges in the homes. This signage is entirely inappropriate and intrusive. Either staff rooms or notice boards should hold such notices – and the ethos of the home in this regard should be enshrined in the staff Codes of Conduct / Practice – but not disturbing the homeliness of the service user’s communal space. Double Room no 29 has been declared in the Statement of Purpose - and was re-measured and confirmed (15.725 sq. m.) at this visit. Being less that 16 square metres in size – the absolute minimum for double occupancy rooms – raises the question of the room’s ‘double’ use. The proprietors are challenged to either develop/increase the size of the room through some means, or to convert the room to single occupancy. The home has a wide range of bathrooms and toilets – all have call bell points – but many call points are poorly situated, such that they would not be of use to service users when in the bath or on / by the toilet. Some call points need splitting to two - to service two areas of the larger rooms. The need to re-site these call points so that they are more convenient to service users is, apparently, ‘on the proprietor’s agenda’ – but work has yet to be undertaken. The inspector had to again explain to the proprietor that minimally weekly checks must be undertaken at each bath and shower outlet - to see what absolute maximum temperature of hot water can be drawn from the tap - in order that it can be confirmed that the thermostatic mixer valves are fully operational, and limiting the water temperature to a top limit of 43 degrees. St Marys Lodge Version 1.10 Page 19 Staff do check and record the temperature of bath water when bathing a service user (which is commendable) - but the risk of scalding / burns can only be properly avoided when valves are installed and properly monitored as described above. There is an extensive secure back garden – leading from a number of points at the rear of the house. There is a concrete patio area with a couple of garden benches that is accessed through well-railed pathways. The garden, with a few rose bushes and shrubs, did not – it seemed – receive a lot of attention; this area could be developed into a far more attractive and functional area for the benefit of a substantial number of service users. St Marys Lodge Version 1.10 Page 20 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, 29, 30. Staffing is provided in sufficient numbers to ensure that the needs of the service users are met at all times, with the skills mix and training providing for appropriate care giving and safe practices within the home. The home’s recruitment practices ensure generally that service users are protected from abuse, though the home must ‘keep up’ with current best practice – relating to checking references and particularly with regard to CRB (Criminal Records Bureau) checks and the PoVA (Protection of Vulnerable Adults) procedures. Induction of staff is also in need of ‘tightening up’. EVIDENCE: Staffing at the home is provided at a level of a proprietor and a minimum of six care staff on duty at any time from 7am to 10pm. Adequate handover times are provided. Night Care staff members are provided at a level of three staff on site - with Mr and Mrs Dudhee, the proprietors asleep, but on call, in their property next door to the home. Cleaning staff members are provided on a daily basis from 7am to 3pm. Staffing in the kitchen has been increased to provide a worker from 3pm to 7pm each day to ensure that a staff member other than a carer addresses suppers and the consequential washing up every night. On checking the most recent staff files created, it became apparent that the home has not been undertaking a Criminal Records Bureau check for necessarily every new staff member at the point of their engagement. St Marys Lodge Version 1.10 Page 21 Elements of ‘portability’ have continued to be been employed – using CRB checks from other/previous employers. It is clear from guidance that staff now may NOT work within a care home without the care home undertaking their own distinct check - incorporating the new Protection of Vulnerable Adult (PoVA) check. A strategy was agreed with the proprietor on how to ensure those checks which were incorrectly processed by the home should be regularised in the shortest possible time. Induction booklets examined for newer staff members were examined on file and found to be wanting: one had only the staff member’s signature in all the boxes (clearly just continuously written in) with no supporting dates, detail or countersignatures of the inductor. Other staff records examined showed that not all files had – as required – copies of a recent photograph (out of date passport copies do NOT count), or verifiably independent references. Although onerous, the proprietors must ensure that the documentation held on each staff member fully meets the requirements of Schedules 2 and 4 of the Care Homes Regulations. The home’s broad selection of policies and procedures have been individually signed and dated by the proprietor – thus designating these documents as the home’s basic statement of intent and conduct. The proprietor relies heavily on the induction booklets to evidence initial engagement with the policies and procedures of the home; this was clearly failing currently (see paragraph two above). Other more long-term staff members had signed a statement at the rear of the procedures manual to state that they had read the whole vast volume – without being at all specific. The home was previously required to ensure that staff signed against an index of the procedures and policies – effectively, therefore, signing against each individual document therein - with their name and date. The staff are thus ‘signed up’ – through this process - to the conduct of the home as the proprietors would require it. St Marys Lodge Version 1.10 Page 22 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, 32, 35, 37 & 38. The home is managed and run by a competent manager and deputy manager, being the registered provider. Service users can be - and are - confident in the attention to the service provided at the home by the managers. The ethos and leadership at the home is clearly expressed by the engagement of the management with staff and the listening ear provided to the opinions of service users and stakeholders. The proprietor’s approach to monetary issues at the home ensures the protection of services users’ financial interests – thus providing protection especially to those who cannot manage their own affairs any longer. Record keeping and the existence of policies and procedures seeks to ensure the best interests of service users, though greater attention should be paid to ensuring that staff fully ‘sign up’ to the approach of the home. With one or two exceptions, the service is maintained in a safe and appropriate way thus providing protection for all service users at the home. St Marys Lodge Version 1.10 Page 23 EVIDENCE: Mr Dudhee has received his CMS certificate in a graduation ceremony in November 2004. He will hopefully complete his other units of NVQ at Level 4 – to complete the Registered Manager’s Award – very soon. He has a sense of direction and leadership. His partner, Mrs Dudhee, is also clearly capable of handling issues at a high level; she is finishing her NVQ at level 3 in Care. She can capably handle meetings (such as service user’s reviews) when necessary. Staff meeting minutes (recorded in detail and signed for by staff members) evidenced the regular coming together of the care staff to discuss issues and to follow through requirements set by this Commission and issues supported by the proprietors. The general feeling within the home was warn and congenial; both staff and management were open and communicative and there was little sense of anxiety apparent with service users. Both proprietors were welcoming, warm and open in their dealings with the inspector. Almost all service users have either relatives or their placing authorities managing their monies for them. The proprietor does not hold any money on behalf of service users –instead, and expenditure is receipted back to the funding agent through an invoicing system. Only one service user continues to maintain their own benefit arrangements and handle their own financial affairs. The proprietor is working to a five-year business plan that guides the spending and development of the home. The proprietor assured the inspector that there is no question that the home is financially viable; occupancy has been maintained reasonably well; there were a few ‘voids’ for a month or two, but mostly the home is close to 100 occupancy. The home is generally well maintained - and the proprietor was able to produce large swathes of papers to prove this and many previous year’s service and maintenance events. The proprietor was advised to have a ‘good clear out’ – archiving previous year’s documents and ordering more clearly the present year or so’s documents. Fire records should also be fully moved in to the new record file book seen at the time of the inspection – and the old collapsing record book archived. One area of absence in maintenance issues was the checking of the water heating and cold water supply systems with regard to contamination by Legionella organisms. The proprietor is required to ensure a competent examination and maintenance check of this entire area. St Marys Lodge Version 1.10 Page 24 Fire doors were also noted, on a number of occasions during the inspection of the entire premises, to be either wedged open or not to be shutting fully on their frames – thus providing a risk of smoke or fume penetration / infiltration in the case of a fire emergency. The home must be assessed for the provision of magnetic door holders or closing arms on fire doors – particularly those on principal fire routes (and very importantly staircases) throughout the home. Closing arms may be more appropriate on doors which presently slam shut noisily – and so have attracted tissues / other substances to quieten the impact of the door closing into the frame. With regard to service users and safety, the use of walking frames is inevitably significant – and the inspector noted a number – especially ‘rollators’ - which had worn through the rubber safety ferrule on the back of the frame. Such exposure of the metal frame can lead to snagging / catching in carpets – and hence presents a safety issue for the service user using the frame. Replacement ferrules must be obtained and fitted and at that point service users must be re-‘inducted’ in using the frame (- the frame won’t just ‘run away’ with the service user any longer!). St Marys Lodge Version 1.10 Page 25 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 3 2 2 3 2 3 STAFFING Standard No Score 27 3 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 3 3 x x 3 x 2 2 St Marys Lodge Version 1.10 Page 26 Are there any outstanding requirements from the last inspection? YES 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 11 Regulation 15(1) (2) Requirement The home must ensure that all the wishes of each service user in relation to steps they may wish to be taken if they are taken [a] seriously ill and [b] have specific requests for last office rites (and any other subsequent arrangements) should be noted, confidentially, in the file / care plan. Timescale of 30.04.05 not met. Timescale for action 30.09.05 2. 22 23(1)(a) & 23(2) (a) (n) A clearly thought-through and 30.09.05 research-based approach to the décor and signage in the home must be universally implemented in order to support and guide particularly the service user group who have dementia. Timescale of 30.04.05 not met. A review of the use of bedroom 29 as a double-occupancy room must be undertaken due to the fact that it is under the NMS size of 16 sq. m. for a double room. Timescale of 30.04.05 not met. A survey of call points in bedrooms where en-suites are provided must be undertaken to Version 1.10 3. 23 23(2)(a) (f) 30.09.05 4. 25 13(4) & 23(2)(n) 30.09.05 St Marys Lodge Page 27 ensure call points are provided close to the toilet and bath where appropriate. Timescale of 30.03.05 not met. 5. 25 13(4) Regular checks of the maximum temperature outflow from hot water taps must be undertaken, with specific records of each test kept -from the time of the inspection visit. Timescales of 18.05.04 and 11.11.04 not met. Staff - wherever their previous employment - must be CRB and PoVA checked by St Marys Lodge before starting work at the home. The use of portability of such checks is no longer permitted as an option to them. Training records - such as induction booklets - must be properly completed to evidence sufficient attention has been shown to this vital area of introducing new staff in the home and its procedures. Policies and procedures must be indexed and staff must sign to confirm that they have read all relevant documents individually signing and dating against such an indexed format (30 & 38). Timescales of 30.10.04 and 30.04.05 not met. Staff files must contain all documentation and content as required by the Care Homes Regulations Schedules 2 & 4. The checking of the homes water supply systems - in line with the Code of Practice on the Prevention of Legionella Version 1.10 11.08.05 6. 29 19(1)-(5) 30.09.05 7. 30 17(2) Sch 4 30.09.05 8. 30 18(1) 30.09.05 9. 37 17 30.09.05 10. 38 13(4) & 23(2) 30.09.05 St Marys Lodge Page 28 including inspection of storage tanks, checking and flushing of pipes, etc. (where necessary) must be undertaken by the home, and added to the regular routine maintenance schedule of the home. 11. 38 13(4) Ferrules on service users walking frames must be regularly checked and changed to ensure that walking equipment remains safe and fitfor-purpose. Exposed metal can catch and create a trip hazard. 30.09.05 12. 38 13(4) & 23(4) Fire doors throughout the home 30.09.05 must be checked regularly for their proper closing onto the door frames; wedges under the door or paper in the doorframe are unacceptable; magnetic door holders or clsing arms integrated with the fire alrm system must be installed to ensure a safe and approved method of holding such doors - is provided. Timescale of 30.04.05 not met. 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 07 Good Practice Recommendations That service user plans - or summaries of the salient actions/goals in bullet point form - should be located closer to the day-to-day notes to ensure consistency of approach and to guide record keeping. That the materials used by the district nursing service are stored in a cupboard or place more appropriate than under the sideboard in the lounge - for infection control and both hygiene and security reasons. Version 1.10 Page 29 2. 08/09 St Marys Lodge 3. 10 That the use of gloves by staff should be reviewed (from a social-acceptance and cross-infection point of view) when taking service users to the toilet. That items such as electric shavers and other personal care paraphernalia should be stored in the privacy of a servise users own room - and that such personal care engagements should only be provided in those locations. That the homes management should monitor the frequency of baths provided to service users, ensuring that the minimum frequency of weekly is indeed adhered to for all those who wish to have such a service. That the home should adopt a system of working with all residents in Life History / Life Story books - creating scrap books concerning their past individual life, leading up to the present day - and involving relatives and friends seeking to build up / restore self-esteem for the individual. (standards 12/13) 4. 10 5. 10 6. 7. 19 That the rear garden area is reviewed and made more accessible atractive to encourage the movement of service users outside and to encourage appropriate and beneficial exposure to sunlight. That notices displayed in the home on lounge walls, such as: No mobile phones - clearly directed at staff - should not disturb the general homely appearance of the service; such instructions should be included in Staff terms of service / conduct - and not in service user areas. That the use of rails / frames around toilets is reviewed especially in larger toilets /bathrooms where grab-rails are not immediately available. That the creaky floorboards in the 1987 wing of the home should be investigated and a solution found to quieten them - thus minimising disturbance to service users. That the management of records / including maintenance documents - and especially the fire precaution records book - should be thinned out - with an ordered process of archiving undertaken - and current papers / books properly ordered to facilitate ease of access. 8. 20 9. 22 10. 24 11. 37 St Marys Lodge Version 1.10 Page 30 Commission for Social Care Inspection 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. 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