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Inspection on 02/10/07 for St Mary`s Lodge

Also see our care home review for St Mary`s Lodge for more information

This inspection was carried out on 2nd October 2007.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

What has improved since the last inspection?

Since the last inspection a number of improvements and service developments have been achieved and the Registered Manager and his staff team are to be commended on making this positive progress. Specifically the following areas of improvements have been achieved and previously set requirements and recommendations met: 1. Improvements have been achieved in the recording and testing of hot water outlets in the home. 2. The laundry room floor has been thoroughly cleaned. 3. All staff who have not been trained to NVQ level 2 standard are now receiving this training.

What the care home could do better:

CARE HOMES FOR OLDER PEOPLE St Mary`s Lodge 81-83 Cheam Road Sutton Surrey SM1 2BD Lead Inspector David Halliwell Key Unannounced Inspection 2nd October 2007 09:30 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 Mary`s Lodge DS0000007144.V351588.R01.S.doc Version 5.2 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 Mary`s Lodge DS0000007144.V351588.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Mary`s Lodge Address 81-83 Cheam Road Sutton Surrey SM1 2BD 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 8661 6215 F/P 020 8661 6215 Mr Jugdutt Dudhee Mrs Marietta Dudhee Mr Jugdutt Dudhee Care Home 40 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (20) of places St Mary`s Lodge DS0000007144.V351588.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th November 2006 Brief Description of the Service: St Marys 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 to present a challenge to the home as it supports those who are mentally sound - alongside those service users with failing memory / mental ability. St Mary`s Lodge DS0000007144.V351588.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection visit undertaken by the Inspector responsible for St. Mary’s Lodge. The Inspection took 2 days to complete and covered all the key standards and involved a tour of the home, a review of all the homes records and formal interviews with 4 staff and the Registered Manager. 4 service users were spoken with formally and more informal interviews were conducted with 6 other Service Users as a part of the tour of the home. 8 requirements have been made as a result of this inspection, 2 of which were outlined at the last inspection. 3 new recommendations have been made. Feedback on these requirements and recommendations was given verbally to the Managers and Proprietors at the end of the inspection visit. The Inspector found the residents and staff very helpful and they are to be thanked for the assistance that they gave him over the course of this inspection visit. The Inspector was impressed by the commitment and enthusiasm of the Manager and of the staff group. The Manager informed the Inspector that the standard fees for a standard residential placement at this home are £380 per week for older people and £419 per week for those people with dementia. 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. The home provides a careful and attentive atmosphere in a friendly environment. Service users clearly feel comfortable at the home, those with mental capacity having an appreciation of the service provided, and those with dementia generally being ‘at ease’ in the house, showing little sign of anxiety or apprehension. The premises are kept generally well ordered and clean. Communal areas are kept as homely as possible - and well-decorated – Mrs Dudhee has a ‘way’ with St Mary`s Lodge DS0000007144.V351588.R01.S.doc Version 5.2 Page 6 floral and ornamental decoration. The home, being an existing (Victorian) building, has its own individual character. What has improved since the last inspection? What they could do better: Specific improvements are now required and recommended in the following areas: Requirements 1. 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. 2. Photographs of each resident must be placed on the medication record sheets so that all staff are sure that they are administering medication to the correct person. 3. Also required is a new medication front sheet that should also be attached to the MAR sheet records. 4. Policies and procedures - staff must sign to confirm that they have read all relevant documents individually signing and dating against such an indexed format. 5. It is essential that the induction process is carried out as prescribed for any new members of staff. It is required that the recent new member of staff receives a full and properly structured induction training forthwith. 6. That all staff are asked to review the key policies and procedures for the home and then to have a discussion in their supervision sessions over a St Mary`s Lodge DS0000007144.V351588.R01.S.doc Version 5.2 Page 7 period of time and then to sign to say that for each individual key policy and procedure that they have read and understood them and have had the chance to discuss them with their supervisor. 7. The Quality Assurance policy should now be fully implemented. 8. That the office and all the staff files and residents’ files and policies and procedures are given a complete and thorough overhaul. Information needs to be clearly marked and logically filed in chronological order to enable easy and ready access to the information required. 9. This should include the development of a training record file that includes: • A training matrix including training undertaken with dates when this was received by staff, • Certificated evidence of training that staff have undertaken, • Future staff training needs identified through supervision and provisional dates as to when this will be supplied. 10. That supervision is held regularly and as prescribed and that detailed supervision records for all staff at St Mary’s Lodge are maintained and kept on site. Recommendations: 1. The Inspector noted that there was not a photograph of the resident on their files and it is recommended that this matter be addressed now. This should assist anybody reading the file to easily recognise the person concerned. 2. That there is clear and specific staff guidance for each resident where PRN medication is being used. This should be drawn up in conjunction with the resident’s GP since this would help protect the resident and ensure that staff are aware of when and when not to give PRN medication as well as making staff aware of any possible side effects for the resident concerned. 3. That effective use of the LBS grant is recommended so as to develop the back garden into a far more attractive - and functional - area for the benefit of residents. This should help make it more accessible and attractive to encourage the movement of service users outside and to encourage appropriate and beneficial exposure to sunlight. 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 St Mary`s Lodge DS0000007144.V351588.R01.S.doc Version 5.2 Page 8 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Mary`s Lodge DS0000007144.V351588.R01.S.doc Version 5.2 Page 9 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 Mary`s Lodge DS0000007144.V351588.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 3 & 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Potential service users may be assured that their needs will be assessed before they move into this home. EVIDENCE: Standard 3 - The Inspector looked at 5 of the 37 residents files during this inspection and found a needs assessment on each of the files seen. The format being used for the needs assessment of the residents is thorough and comprehensive in it’s coverage of all aspects of a potential service user’s needs. It covers the following areas: 1. Physical and mental abilities 2. Health and hygene 3. Food and dietary needs St Mary`s Lodge DS0000007144.V351588.R01.S.doc Version 5.2 Page 11 4. Spiritual, social and religious needs 5. And a risk assessment that identifies any risks which might affect the resident and in order to create good working practices to protect them. The completion of this needs assessment format on the files inspected was good with some information provided on all the areas mentioned. In addition to this the referring agencies had completed their own needs assessment of the service users at the time of placing their service user at St. Mary’s. This information was seen on files inspected. The Registered Manager informed the Inspector that in all cases a needs assessment in carried out at the time of placement at St. Mary’s and this was supported by evidence seen on the files inspected. Standard 6 - The Registered Manager informed the Inspector that no intermediate care is provided at St. Mary’s so Standard 6 is not appropriate and has not therefore been assessed. St Mary`s Lodge DS0000007144.V351588.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 & 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users may be assured that their health and social care needs will be set out in an individual care plan and that their health needs will be met. The policies and procedures for the administration of medication should help protect them. Residents in the home feel that they are treated with dignity and respect. EVIDENCE: Standard 7 - 4 residents files were inspected at this inspection and on all 4 files there was an up to date care plan that could be seen to be being reviewed monthly. Associated action planning was also seen that should assist staff to help the residents make progress in meeting the care plan objectives. The reviews had all been signed off by the Manager and the Keyworker for the resident concerned. All but one of the care plans had been reviewed in the last month and the Manager assured the Inspector that the review of that care plan St Mary`s Lodge DS0000007144.V351588.R01.S.doc Version 5.2 Page 13 would be carried out in the near future. He also told the Inspector that should the needs of any resident change then a review of the assessment and of the care plan would occur. Care plan information included all the key information details for the service user including the name and address of their relatives and next of kin; information about their GPs; the date of the service users admission to the home; the appropriate details of the referring agencies which placed the service users; a record of all the medicines administered to the service users and any other relevant information to the provision of care for the service user concerned. The Registered Manager told the Inspector that because many of the residents suffer from dementia this makes involvement in the structuring of the care plans quite difficult however where ever possible all service users are involved in the development of their care plans and have signed their care plans in agreement to their content. Often where appropriate service users families or relatives or representatives will be involved when the service user themselves is unable to participate in the care planning process. At the last inspection a recommendation was made to ensure that resident’s care 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. At this inspection the Inspector saw that some progress had been made in that this information is now held on the daily record book that all care staff should regularly look at. However the information included lacked sufficient detail to be useful to care staff and it is now a requirement that this area of work must be further developed so that it becomes “fit for it’s purpose”. The Inspector noted that there was not a photograph of the resident on their files and it is recommended that this matter be addressed now. This should assist anybody reading the file to easily recognise the person concerned. Standard 8 – The Manager told the Inspector that 4 residents had been admitted to accident and emergency since the last inspection. Accident records were seen by the Inspector that showed the reasons had been due residents’ falls. The Manager also told the Inspector that there are no residents at present living in the home who have pressure sores. Some residents have leg ulcers and these residents he said are looked after by the District Nurses who attend the home 2 or 3 times a week. The Manager told the Inspector that he has now provided a treatment room for the District Nurses that has been made available for wound management and treatment given to the residents by the District Nurses. St Mary`s Lodge DS0000007144.V351588.R01.S.doc Version 5.2 Page 14 The Registered Manager informed the Inspector that all the service users do have access to a GP and that they also have a choice of GP from the local area in Sutton. The Registered Manager also told the Inspector that all residents have access to the following health care professionals who visit St. Mary’s on a regular basis. The optician visits every 6 months; the dentist also now visits once every 6 months and the chiropodist also visits on regular basis every 3 months. Dietary needs are assessed for each service user at the time of their admission and then re-assessed as required this includes a nutritional assessment. Evidence of this was seen by the Inspector on the service users files as a part of their care plans. Standard 9 - The Inspector was provided with the agencies policies and procedures manual by the Registered Manager and this file included an appropriate medication policy for the unit. The Registered Manager told the Inspector that the usual practice for the administration of medicines at St. Mary’s is for him to give the residents their medication. However the Manager also said that on occasions other senior care staff would be asked by him to give the residents their medication. Several of the senior staff are registered nurses and have the training and experience necessary to do so. None of the current residents self medicate. Appropriate records (MAR sheets) were seen to have been completed properly for the period and for the administration of medicines to residents. The Inspector asked the Manager whether there is clear and specific staff guidance for each resident where PRN medication is being used. The Manager told the Inspector that this has not been done. It is therefore recommended that this be drawn up in conjunction with the resident’s GP since this would help protect the resident and ensure that staff are aware of when and when not to give PRN medication as well as making staff aware of any possible side effects for the resident concerned. It is also required that photographs of each resident be placed on the medication sheets so that all staff are sure that they are administering medication to the correct person. This should be part of a newly drawn up front sheet that needs to be attached to the MAR sheet records. This was discussed in detail with the Manager. A check carried out by the Inspector at this inspection for medicines remaining in the stores against the recorded levels proved correct and no errors were found in the system. St Mary`s Lodge DS0000007144.V351588.R01.S.doc Version 5.2 Page 15 The storage of medicines was seen to be completely appropriate including refrigerated cupboards where necessary. The Manager told the Inspector that no residents currently use controlled drugs. Training records were presented to the Inspector for the care staff who had all received training in September 2006 to do with the safe handling of medications. Standard 10 - The Inspector spoke with 6 of the 37 residents at St. Mary’s about the quality of the care they receive to meet their needs. Although the presence of dementia for the service users in varying degrees of progression did make this sometimes rather difficult the Inspector was impressed with the positive remarks made by service users about the care and support that they receive from staff at St. Mary’s. The Inspector was also impressed by the commitment of the 4 staff, formally interviewed by the Inspector, to maintaining the dignity and privacy of the residents wherever possible. All the residents receive personal care and are helped with washing and bathing, dressing and toileting. All residents have their own laundry baskets operated by the care staff and their laundry is washed in a systematic way so as to ensure they are able to wear their own clothes. The staff induction programme which all new staff has to work through covers the core standards of privacy, dignity, independence, civil rights, fulfilment and choice. Evidence seen by the Inspector on the staffing files showed that all new staff has received this training. St Mary`s Lodge DS0000007144.V351588.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users / residents are likely to find that the lifestyle they experience at St. Mary’s matches their expectations and their preferences and satisfies their social, cultural, religious and recreational interests. Residents are encouraged to maintain contacts with their friends and families and service users are helped to exercise choice and control in their lives wherever possible. The meals and food provided to residents is well balanced, healthy and varied. EVIDENCE: Standard 12 – The Manager told the Inspector about the home’s programme of entertainment and events, which are provided for the service users and residents. Bingo, music and singing, skittles and other board games are some of the things on offer to the residents. The Inspector spoke to 6 of the St Mary`s Lodge DS0000007144.V351588.R01.S.doc Version 5.2 Page 17 residents and asked them all whether they enjoyed the different forms of entertainment offered to them. Most residents said that they do enjoy what is offered but some also said they would like a wider variety to choose from. It is suggested therefore that the Registered Manager ask the residents and their relatives or representatives as a part of the quality assurance process what they would like to see in the way of developments in this area. The Manager informed the Inspector that the resident’s religious and cultural needs are assessed as a part of their initial assessment and placement at St. Mary’s. Evidence of this was seen on the resident’s files and specifically in their needs assessments. The Manager told the Inspector that an Anglican Minister attends the home monthly and also a weekly Catholic service is held in the home. This was seen to be happening in the home on the second day on the inspection. Standard 13 – The Inspector was told by the Manager and the staff that there are no specific visiting hours and that as long as a resident wishes to see a relative then visitors are welcome at most times of the day. A record of visitors was seen and there is a room as well as the resident’s own bedrooms where relatives, families and friends can be seen in private if they wish. Residents confirmed this with the Inspector. Standard 14 – This standard explores issues relating to: managing financial affairs, advocacy, respecting of the right to personal possessions, and enabling access to information kept concerning a service user. A number of service users still have some control over their own affairs; this is encouraged, where appropriate and assessed on admission to the home. Obviously - especially in regard to service users with dementia - relatives or advocates / solicitors or local authority personnel are often heavily involved. The Inspector noted advertisements for local advocacy services in the front hallway of the home, where service users and their relatives often pass. Permission is positively given to service users who wish to bring in items of furniture or other familiar items when entering the home; the only proviso is that these items be safe from the point-of-view of fire and soundness. Standard 15 – As a part of the inspection the Inspector spoke with on of the Proprietors who said that the Chef had left recently and in the interim she is doing the cooking of the meals in the home. The menu planning and the food provided to the residents was discussed. A 3-week rolling menu is provided and the Manager draws that this up after consultation with the residents who are asked what they would like to eat. Any special dietary requirements are also taken into account and provision is made in the menu plan. The Inspector saw both the 3-week menu plan and the daily menus and these menus provide a wide and healthy range of food for the residents. The Inspector was present for the lunch and evening meals and was able to speak to the residents at these times about the food. All the residents who were asked by the Inspector St Mary`s Lodge DS0000007144.V351588.R01.S.doc Version 5.2 Page 18 said that they like the food on offer to them and they confirmed that they do have a choice. One resident to whom the Inspector spoke is a vegetarian and she said she really enjoys the vegetarian options she is offered at St. Mary’s. Menus are displayed in each of the 3 dining rooms and this enables the residents to see what they will have to eat and what choices they have on a daily basis. Care staff was seen to provide assistance to the residents when this was necessary and staff were seen to ask the residents before they offered any help to them. Meal times were seen to be unhurried and any resident who chose to eat in their bedrooms was enabled to do so. The Proprietor said that all the requirements made by the Environmental Health Officer’s last visit had now been addressed. The Inspector reviewed the report and saw the improvements and the works in the kitchen that were required, had indeed been completed. The Manager informed the Inspector that a nutritional assessment is undertaken as a part of the residents needs assessments and any special needs are catered for in the menu planning. St Mary`s Lodge DS0000007144.V351588.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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. Service users can be assured that the processes in the home will protect them from potential abuse by staff or others. EVIDENCE: Standard 16 – The Registered Manager showed the Inspector the complaints policy and procedure for St.Mary’s. This policy covers all the essential areas required for a complaints policy including a staged process with timescales and contacts for other agencies including the CSCI to contact in the event of dissatisfaction with the internal process of investigation. The Registered Manager maintains a record of complaints book and the Inspector saw this. No complaints were recorded since the last inspection. Standard 18 – A copy of the Adult Protection policy was shown to the Inspector by the Manager. Staff interviewed were able to confirm that they had been on this training however from the interviews with staff the Inspector identified a need to further embed the principles of the policy. There was a discussion with the Registered Manager about this St Mary`s Lodge DS0000007144.V351588.R01.S.doc Version 5.2 Page 20 and it was agreed that further discussion needs to be had with staff in the supervision process. Evidence was seen by the Inspector in certificated form that all staff had attended POVA training in June and July 2006. The Manager was reminded that staff will need refresher training on this subject next year. The Manager informed the Inspector that this is in fact planned for November 2007. Staff members are all now thoroughly vetted and recruitment assures that nobody starts at the home until their credentials with regard to the Criminal Records Bureau (CRB) and the Protection of Vulnerable Adults Register have been checked. The Inspector reviewed 4 of the staffing files and found valid CRB enhanced checks for all these staff. The Manager confirmed he was conversant with the procedure for referral of staff to the Vulnerable Adults ‘List’ - if this became necessary. The home’s policies and procedures - created by a reputable company - cover all essential areas of guidance, including physical intervention, service user’s finances, insurance and such issues as gifts gratuities and bequests. St Mary`s Lodge DS0000007144.V351588.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be assured that the house is safe and well maintained, that it is clean and hygienic. Communal lounge and dining facilities are homely, warm and generally comfortable; toilets and bathrooms are suitable to service users with emergency call bell provision now being appropriately provided. Bedrooms are both safe and comfortable, meeting each individual’s needs with all basic amenities provided. EVIDENCE: Standard 19 - the Inspector together with the Manager undertook a tour of the premises. This was a part of the inspection and the home was seen to be clean and tidy in all areas. There are areas of the home, which are not accessible for St Mary`s Lodge DS0000007144.V351588.R01.S.doc Version 5.2 Page 22 wheelchair users although there is a lift, which provides access to all floors of the building. The general condition of the home and the facilities is good; communal areas and bedrooms are kept clean and odour-free. The proprietors provide a ‘homely’ touch through supplementary decoration and ornaments / flower decorations and pictures hanging on all the walls. The complicated physical layout of the home means that finding one’s way around this home can be quite difficult. The home has a wide range of bathrooms and toilets all now having been upgraded by the Manager including call bell points being situated where they are of use to service users when in the bath or on / by the toilet; extension leads have been appropriately provided. The Manager informed the Inspector that checks on each of the four boiler outlets which each provide different areas of the home with hot water are checked on a weekly basis so that over a period of one month all the hot water outlets are temperature checked. Records of these checks were seen by the Inspector and all the checks showed that hot water temperatures are within the safe and prescribed limits. A previous requirement made at the last inspection has therefore now been met. The hot water check is designed to see what the 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. Staff do, apparently, check and record the temperature of bath water when bathing a service user (which is commendable) - but the risk of scalding / burns (which can occur in unusual situations) can only be properly avoided when valves are properly and regularly monitored. There is an extensive and secure back garden – leading from a number of points at the rear of the house. The Manager informed the Inspector that L.B.Sutton has this year awarded St. Mary’s a grant that is to be used to improve the facilities in the back garden. He said that this will be used to raise some of the flower beds so that disabled residents can access them to do some gardening if they wish. Also to provide a covered arbour. There is at present a concrete patio area with a couple of garden benches that is accessed through well support-railed pathways. The garden, with a few rose bushes and shrubs, has not received a lot of attention and so the effective use of this grant is recommended so as to develop it into a far more attractive - and functional - area for the benefit of residents. Bathing equipment - such as bath seats and non-slip mats at this inspection were noted to be cleaner than at the last inspection and so the requirement concerning this that was made at the last inspection has now been met. St Mary`s Lodge DS0000007144.V351588.R01.S.doc Version 5.2 Page 23 Standard 26 – As already indicated above, the home was found at this inspection to be clean and free from offensive odours. The Inspector toured the unit together with the Registered Manager and inspected all areas of the home. 8 of the service users bedrooms were seen and were found to be clean and tidy and all the residents spoken to by the Inspector said that their bedrooms are decorated and furnished as they would wish. The Registered Manager showed the Inspector the home’s an infection control procedure, which seems to be effective. He told the Inspector that the home has a contract with a company that deals with clinical waste and evidence of this was seen by the Inspector. Staff interviewed confirmed that they are issued with appropriate clothing and equipment for them to carry out their work appropriately The laundry area is well laid out and there is an impermeable floor. At the last inspection a requirement was made to ensure that the floor at the rear of the washing machines be thoroughly cleaned and tidied up. This requirement has now been met and at the time of this inspection the room was seen to be clean. St Mary`s Lodge DS0000007144.V351588.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 & 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users may be assured that the numbers of staff and the skill mix that they provide at St. Mary’s will meet their needs. The recruitment policy and procedure at St. Mary’s does support and protect the service users. Staff are being trained appropriately and when the measures described below are achieved then service users will be able to be assured that the staff are fully competent to do their jobs. EVIDENCE: Standard 27 – the Registered Manager provided The Inspector with a staffing rota for St. Mary’s. The rota shows exactly who is working for the week. The Manager informed the Inspector that there are always 5 care staff on duty and 2 managers for both the morning shifts and the afternoon and evening shifts. The rota provided supported this statement. Given that that there are 37 residents living at St. Mary’s at present the staff: resident ratio mix seems adequate to meet the needs of the residents. The Registered Manager also informed the Inspector that there are 4 staff on duty overnight – 3 waking staff and 1 sleeping in staff member. Also that there is always a Manager on St Mary`s Lodge DS0000007144.V351588.R01.S.doc Version 5.2 Page 25 call. Both Mr Dudhee – the Registered Manager and his wife, Mrs Dudhee, the Deputy Manager live in the adjoining property to St. Mary’s and so are able to be on hand fairly readily. The home also has kitchen and domestic staff who the Inspector met over the course of this inspection. The Registered Manager told the Inspector that no agency staff are used at St. Mary’s. Standard 28 - The Manager told the Inspector that there are 15 care staff in total including senior carers but excluding the Manager and Deputy Manager. Of these 15 care staff, 3 are Registered Nurses and 4 staff are currently undertaking their NVQ training. 8 care staff already have achieved their NVQ 2 qualifications. The Manager showed the Inspector appropriate documentation for those staff that does have NVQ level 2 and also for his own NVQ level 4 and for his Deputy who has NVQ level 3. The Registered Manager is a qualified NVQ assessor and the qualifications for this were shown to the Inspector. Standard 29 – St. Mary’s does have a recruitment procedure that was inspected and seen to be appropriate for it’s purpose. As a part of this inspection the Inspector reviewed 4 of the staffing files. Applicants are interviewed, application forms completed, two written references gained, enhanced Criminal Record Bureau checks undertaken and documentation regarding all these parts of the recruitment process are held on staffing files in the main office at St. Mary’s. The Inspector saw evidence that this process is being properly implemented. Contracts with staff were also seen on the staffing files. Standard 30 – The Manager informed the Inspector that since the last inspection there has been a new member of staff who joined the team in the last 2 months. When the Inspector asked the Manager if that member of staff had yet completed their induction, the Manager said that it had not yet been carried out. After some discussion the Manager agreed that the new member of staff should have received some induction training from day one and then at staged intervals thereafter. Although the Manager explained that this new member of staff is being mentored and supervised it is essential that the induction process is carried out as prescribed for any new members of staff. It is required that this new member of staff receive a full and properly structured induction forthwith. Induction booklets examined at random for newer staff members were examined and still found to be wanting: more than one had only the staff member’s signature in all the boxes with no supporting dates, detail or St Mary`s Lodge DS0000007144.V351588.R01.S.doc Version 5.2 Page 26 countersignatures of the inductor. The proprietor relies heavily on the induction booklets to evidence initial engagement with the policies and procedures of the home; this was clearly still failing. Other, more long-term staff members had signed a statement at the rear of the procedures manual to state that they had read this whole vast volume – without being specific. In order for this process to be more fully implemented and so as to benefit residents in that the staff will know and understand what the stated policies and procedures are, it is a requirement that all staff are asked to review the key policies and procedures for the home and then to have a discussion in their supervision sessions over a period of time and then to sign to say that for each individual key policy and procedure that they have read and understood them and have had the chance to discuss them with their supervisor. St Mary`s Lodge DS0000007144.V351588.R01.S.doc Version 5.2 Page 27 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36, 37 & 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a home that is run by a person who is fit to be in charge and is able to discharge his responsibilities. The quality assurance system is not yet fully implemented and so it is difficult to be absolutely clear that the home is being run in the best interests of the residents. The Manager’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. Supervision practices do however need some development and improvement. Record keeping also needs to be improved as described in this section of the report. 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. St Mary`s Lodge DS0000007144.V351588.R01.S.doc Version 5.2 Page 28 EVIDENCE: Standard 31 – The Manager and the Deputy Manager, Mr and Mrs Dudhee are also the proprietors of St. Mary’s. Both have been in their management roles at St. Mary’s for over 15 years and do hold the necessary experience to undertake their roles. Mr. Dudhee showed the Inspector documentary evidence to prove their management and NVQ qualifications – Mr Dudhee holds an NVQ level 4 and Mrs Dudhee and NVQ at level 3. Supplementing this experience and training both the Manager and Deputy Manager update their training portfolios appropriately and evidence that this is so was shown to the Inspector. Mr Dudhee received his CMS certificate in November 2004. He has now completed his NVQ ‘A1’ Assessor’s Course in June 2006. Standard 33 – The Manager showed the Inspector the home’s Quality Assurance file that has been provided by a consultancy company. As a result it is a completely comprehensive document that if it had been fully and consistently implemented would ensure that St. Mary’s has one of the very best quality assurance processes. The fact that at this inspection as with the previous inspection in 2006 there has only been partial implementation is regrettable. This was discussed in detail with the Manager who agreed that it must now become a priority to ensure full implementation over the next year. The Manager showed the Inspector some surveys that had been recently sent out to service users and their relatives and since returned. All 37 of the residents had been surveyed and 10 out of 20 relatives had returned a completed questionnaire. One or two of the visiting professionals to the home had also been surveyed and had returned their forms completed. This form of feedback needs to be extended and the feedback analysed and published. Any findings that come from the analysis should be used together with other feedback sources to inform an annual development and improvement plan. It is a requirement now that the QA policy is fully implemented. The general feeling within the home was warm and congenial; both staff and management were open and communicative and little sense of anxiety was apparent with service users. Both proprietors were again welcoming, warm and open in their dealings with the Inspector. Standard 35 – The Manager told the Inspector that St. Mary’s does not look after residents monies directly and that if a resident does need something to be purchased the Manager may make the purchase but only after speaking with the resident’s relative or representative who then will repay St. Mary’s. St Mary`s Lodge DS0000007144.V351588.R01.S.doc Version 5.2 Page 29 Standard 36 - The Manager informed the Inspector that care staff should now be receiving formal supervision at least once every 4 – 6 weeks and informal supervision more often, sometimes on a daily basis. The Inspector saw supervision records for staff that are held on their files. Supervision records however held on staffing files did not evidence that regular supervision for all staff is taking place in the required timeframe. Inspection of the records showed that they were very brief and they did not contain sufficient detail where discussions had been had with key working staff about the work they are doing with residents in meeting their care plan objectives. Supervision sessions should include the monitoring and review of work objectives, the training needs required by the staff member in order to carry out their work and any other issues that have arisen in supervision. Both the member of staff and the supervisor should sign off these records. It is required that supervision is held regularly and as prescribed and that detailed supervision records for all staff at St Mary’s Lodge are maintained and kept on site. By doing so it should improve the quality of supervision and support offered to staff and the quality of care delivered to tenants. The Inspector spoke with the Manager about supervision practices and confirmed that supervision sessions held with staff should include the monitoring and review of all aspects of care practices, the philosophy of care in the home and also career and training development needs. Areas of discussion should also cover the monitoring and review of any individual work with resident’s care plans objectives. The supervision record should detail any agreements made, revised work objectives and key areas of discussion. The Inspector suggested to the Manager that all staff providing staff supervision should receive training on staff supervision so as to ensure that supervision and staff appraisals are carried out consistently and effectively. Standard 37 – Over the last 2 years of inspections concerns have been raised with the Manager over the storage and filing of information in the main office at St Mary’s. During this inspection it became clear that once again information required to be seen is not always easily available for inspection. Information that should be held together is often scattered about and is not grouped together as one would expect. The Manager understands that this is a problem and whilst he can usually find the information given time it is now an essential requirement that the office and all the staff files and residents files and policies and procedures are given a complete and thorough overhaul. Information needs to be clearly marked and logically filed in chronological order to enable easy and ready access to the information required. St Mary`s Lodge DS0000007144.V351588.R01.S.doc Version 5.2 Page 30 This should include the development of a training record file that includes: 1. A training matrix including training undertaken with dates when this was received by staff, 2. Certificated evidence of training that staff have undertaken, 3. Future staff training needs identified through supervision and provisional dates as to when this will be supplied. Standard 38 - the Manager showed the Inspector a maintenance record book for the home which details all the maintenance requirements and how and when they have been resolved. The home is generally well maintained and the process seems to work well. The Manager informed the Inspector that he carries out a room-by-room risk assessment in the unit and evidence of this was shown to the Inspector. The last risk assessment was carried out in February and March 2007. A health and safety audit was carried out in August 2007. The policies and procedures manual includes polices on health and safety, risk assessment, moving and handling and fire risk awareness. The Manager is reminded that all staff should receive training in the following areas at least once every 2 years: • Protection of vulnerable adults • Food hygiene • COSSH • First Aid • Safe handling of medicines • Moving and handling • Dementia awareness Certificates were also checked and seen by the Inspector for the following services that are installed in the home, certificates which state that these systems have been checked by appropriate professionals since the last inspection and found to be satisfactory and fit for purpose. 1. Boiler / gas – 17.7.07 2. Electrical system check – 18.7.07 3. Lift – 12.2.07 4. Fire alarms – 16.2.07 5. Emergency lighting system – 3.10.07 6. Fire fighting equipment – 25.5.07 7. Water check for legionella organisms – 29.8.07 8. Hoist and bath lift – 26.7.07 9. Portable electrical equipment – 26.3.07 Records were seen and checked by the Inspector as satisfactory for: 1. Weekly fire alarm tests last tested w/b 3.10.07 St Mary`s Lodge DS0000007144.V351588.R01.S.doc Version 5.2 Page 31 2. Staff fire drills every 2 months 3. Fire extinguishers visually checked monthly St Mary`s Lodge DS0000007144.V351588.R01.S.doc Version 5.2 Page 32 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 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 2 3 St Mary`s Lodge DS0000007144.V351588.R01.S.doc Version 5.2 Page 33 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 OP7 Regulation 14 Requirement 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 photographs of each resident be placed on the medication record sheets so that all staff are sure that they are administering medication to the correct person. Timescale for action 01/12/07 2. OP9 13 01/12/07 3. OP30 18(1) Also required is a new medication front sheet that should also be attached to the MAR sheet records. Policies and procedures - staff 01/12/07 must sign to confirm that they have read all relevant documents individually signing and dating against such an indexed format. It is essential that the induction process is carried out as prescribed for any new members of staff. It is required that the DS0000007144.V351588.R01.S.doc 4. OP30 18 01/11/07 St Mary`s Lodge Version 5.2 Page 34 recent new member of staff receives a full and properly structured induction training forthwith. 5. OP30 18 That all staff are asked to review the key policies and procedures for the home and then to have a discussion in their supervision sessions over a period of time and then to sign to say that for each individual key policy and procedure that they have read and understood them and have had the chance to discuss them with their supervisor. The Quality Assurance policy should now be fully implemented. That the office and all the staff files and residents files and policies and procedures are given a complete and thorough overhaul. Information needs to be clearly marked and logically filed in chronological order to enable easy and ready access to the information required. This should include the development of a training record file that includes: 1. A training matrix including training undertaken with dates when this was received by staff, 2. Certificated evidence of training that staff have undertaken, 3. Future staff training needs identified through supervision and provisional dates as to when this will be supplied. St Mary`s Lodge DS0000007144.V351588.R01.S.doc Version 5.2 Page 35 01/12/07 6. OP33 24 01/12/07 7. OP37 17 01/12/07 8. OP36 18 That supervision is held regularly and as prescribed and that detailed supervision records for all staff at St Mary’s Lodge are maintained and kept on site. 01/12/07 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 OP7 Good Practice Recommendations The Inspector noted that there was not a photograph of the resident on their files and it is recommended that this matter be addressed now. This should assist anybody reading the file to easily recognise the person concerned. That there is clear and specific staff guidance for each resident where PRN medication is being used. This should be drawn up in conjunction with the resident’s GP since this would help protect the resident and ensure that staff are aware of when and when not to give PRN medication as well as making staff aware of any possible side effects for the resident concerned. That effective use of the LBS grant is recommended so as to develop the back garden into a far more attractive - and functional - area for the benefit of residents. This should help make it more accessible and attractive to encourage the movement of service users outside and to encourage appropriate and beneficial exposure to sunlight. 2. OP9 3. OP19 St Mary`s Lodge DS0000007144.V351588.R01.S.doc Version 5.2 Page 36 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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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