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Inspection on 20/11/06 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 20th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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. The signage required at the last inspection has been placed around the home and this has improved the orientation and understanding of the home`s layout for some of the residents. 2. Fire alarm testing has been undertaken on a weekly basis and a record made of the findings. 3. Bathing equipment in use for the residents has been inspected and seen to be appropriately clean and fit for purpose. 4. Training records have been improved and the previous requirement is now met. 5. the Home`s water system has been checked for Legionella disease and passed as satisfactory and the previous requirement is now met. 6. Some care plan summaries have been added to the key information sections of the daily log but this process has not been completed yet for all residents and this should be done as soon as possible.

What the care home could do better:

Specific improvements are now required and recommended in the following areas: 1. Social entertainment programme could be expanded and residents asked what additions they would like to see made to the existing programme. 2. Recent training of staff in the protection of vulnerable adults needs to be embedded through the supervision process (see also 6 below). 3. Improvements are still required for the recording and testing of hot water outlets in the home. 4. The laundry room floor is required to be thoroughly cleaned. 5. All staff will need to be NVQ trained to level 2 by next year 2007. 6. Staff must have a chance to discuss in supervision all policies and procedures and sign and date to say that they have read them. 7. Staff should be issued with staff handbook files. 8. The Quality Assurance policy must be fully implanted. 9. Summaries of residents care plans must be added to the key information slots in the daily logs for all residents. 10. Life story books should be developed by key workers for all residents wherever possible. 11. the management of records and documentation should be improved so that the Manager has one file with all the up to date and most recent documentation and other older documents archived.

CARE HOMES FOR OLDER PEOPLE St Mary`s Lodge 81-83 Cheam Road Sutton Surrey SM1 2BD Lead Inspector David Halliwell Key Unannounced Inspection 20th November 2006 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.V320104.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.V320104.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 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.V320104.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd February 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 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.V320104.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 new Inspector responsible for St. Mary’s Lodge. The Inspection covered all the key standards and involved a tour of the home, a review of all the homes records and formal interviews with 3 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. 2 new requirements have been made as a result of this inspection, 5 of the previous 7 requirements have since the last inspection been met. 4 new recommendations have been made. Feedback on these requirements and recommendations was given verbally to the Manager 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 £??? per week. 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 floral and ornamental decoration. The home, being an existing (Victorian) building, has its own individual character. St Mary`s Lodge DS0000007144.V320104.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Specific improvements are now required and recommended in the following areas: 1. Social entertainment programme could be expanded and residents asked what additions they would like to see made to the existing programme. 2. Recent training of staff in the protection of vulnerable adults needs to be embedded through the supervision process (see also 6 below). 3. Improvements are still required for the recording and testing of hot water outlets in the home. 4. The laundry room floor is required to be thoroughly cleaned. 5. All staff will need to be NVQ trained to level 2 by next year 2007. 6. Staff must have a chance to discuss in supervision all policies and procedures and sign and date to say that they have read them. 7. Staff should be issued with staff handbook files. 8. The Quality Assurance policy must be fully implanted. 9. Summaries of residents care plans must be added to the key information slots in the daily logs for all residents. 10. Life story books should be developed by key workers for all residents wherever possible. 11. the management of records and documentation should be improved so that the Manager has one file with all the up to date and most recent documentation and other older documents archived. St Mary`s Lodge DS0000007144.V320104.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Mary`s Lodge DS0000007144.V320104.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection St Mary`s Lodge DS0000007144.V320104.R01.S.doc Version 5.2 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. 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 from evidence gathered both during and before the inspection visit to this service. Service users may be assured that their needs will be fully assessed before they move into St. Mary’s and that through the care plans these needs will be met. 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. EVIDENCE: Standard 3 - The Inspector looked at 4 of the 39 residents files during this inspection and found a comprehensive needs assessment on each of the files St Mary`s Lodge DS0000007144.V320104.R01.S.doc Version 5.2 Page 10 seen. The referring agencies had all completed their own needs assessment of the service users at the time of placing their service user at St. Mary’s. St. Mary’s staff then undertake their own needs assessment using the information from the referring agency and from their own assessment of the service users needs. Wherever possible the service users or their representatives are involved in this process. Areas of need assessed and seen by the Inspector in these needs assessments are: • Personal care and well being of the service user • Dietary needs • Sight, hearing and communication • Oral health • Foot care • Continence • Medication usage • Mental and physical state • Social interests • Religious and cultural needs 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. 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.V320104.R01.S.doc Version 5.2 Page 11 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 good. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Service users can be assured that their health, personal and social care needs will be the central focus of their care plans and that these plans will be appropriately reviewed as and when required. Service users can also be assured that their healthcare needs will also be met at St. Mary’s. Medication administration is appropriately managed and properly recorded and stored, and residents are being protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: Standard 7 – As already indicated above, over the course of this inspection, the Inspector inspected 4 of the 39 service users files taken at random. In St Mary`s Lodge DS0000007144.V320104.R01.S.doc Version 5.2 Page 12 each of these files a comprehensive needs assessment was seen and also a care plan. The Care plans were properly set out in a very useful format that makes for logical reading and ensures that all aspects of service users needs will be considered when devising the care plan. Space on the care plan is provided for a photograph of the service user / resident but only on one of t he service user files had a photograph been placed. The Registered Manager told the Inspector that this error would be rectified straight away so that easy identification of the service user is possible for all staff accessing the care plans. 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 can make full 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. Risk assessments were seen by the Inspector for service users on all the files inspected and these risk assessments were also seen to be reviewed monthly and updated where needs have changed. Standard 8 – This standard is concerning the healthcare of each of the service users. 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 once every year and the chiropodist also visits on regular basis. 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 and staff formally interviewed also said that this was the usual practice as a part of the assessment process for service users. Standard 9 – The Inspector was provided with the agencies policies and procedures manual by the Registered Manager and this file included an St Mary`s Lodge DS0000007144.V320104.R01.S.doc Version 5.2 Page 13 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 service users 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 service users self medicate. Appropriate records (MAR sheets) were seen to have been completed properly for the administration of medicines to service users. 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 10 of the 39 residents and service users 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 3 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. Care staff interviewed showed the Inspector by their responses their caring attitude towards the residents and service users in their comments about staff also reflected this. Many of the bedrooms in the new wing of the building built in the 1980s have en suite toilet and bathing facilities and this also helps residents to maintain a level of privacy that they seemed to welcome. 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.V320104.R01.S.doc Version 5.2 Page 14 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 from evidence gathered both during and before the inspection 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 - During the course of this inspection the Inspector saw a 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 10 of the residents and asked them all whether they enjoyed the different forms of St Mary`s Lodge DS0000007144.V320104.R01.S.doc Version 5.2 Page 15 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 recommended 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. Residents are encouraged to attend church if they wish to and staff will assist them to do so. 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 the Chef and discussed the menu planning and the food provided to the residents. The L.B.Sutton had issued a report earlier in the year to do with food hygiene. Some kitchen improvements were required and a general upgrade was also discussed and work done since the report inspected. The chef informed the Inspector that there is a 3-week rolling menu planner 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.V320104.R01.S.doc Version 5.2 Page 16 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 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. All the points raised in the L.B.Sutton’s recent report were inspected at this inspection and were seen by the Inspector to have been satisfactorily addressed and all issues resolved to a good standard. These issues included the following items: • • Fridge and freezer daily temperature tests – records were seen for daily recordings and temperatures were all within the acceptable limits, Areas of the kitchen walls were required to be repainted – this had been done and the whole kitchen has been refurbished with newly painted walls and ceiling, a new floor covering and all cracked tiles have been replaced. New lighting has been installed where necessary. All areas including the fans have been professionally cleaned. • • The kitchen was seen to be in very good order by the Inspector and the menus offer residents a healthy, varied choice of food that they all said they enjoy. St Mary`s Lodge DS0000007144.V320104.R01.S.doc Version 5.2 Page 17 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): Standards 16 & 18. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the inspection 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 – St. Mary’s has an Adult Protection policy and the Registered Manager was able to produce a copy of Staff interviewed were able to St Mary`s Lodge DS0000007144.V320104.R01.S.doc Version 5.2 Page 18 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 and it was agreed that further discussion needs to be had with staff in the supervision process. This is a recommendation. the 2005 revised local authority (LB Sutton) Adult Protection policy and procedure. All staff have recently been on a training course covering the protection of vulnerable adults and the Inspector was shown the training certificates for this training. 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 proprietor 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.V320104.R01.S.doc Version 5.2 Page 19 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 from evidence gathered both during and before the inspection 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. Service users’ own bedrooms are distinctively different, and offer scope for the personalisation that the home encourages. Bedrooms are both safe and comfortable, meeting each individual’s needs with all basic amenities provided. St Mary`s Lodge DS0000007144.V320104.R01.S.doc Version 5.2 Page 20 EVIDENCE: Standard 19 – A tour of the premises was undertaken by the Inspector as 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 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 home more recently redecorated one of the lounges in a distinctive colour the ‘blue room’ – to ‘anchor’ / orientate service users in their familiar environment. At the last inspection a need was identified to ensure that the house develops improved ‘sign-posting’ for service users – more especially those with dementia - but also both those who are relatively competent, to ensure that all are as assisted in being oriented in time and place. A requirement was made to increase the signage and this has been done with the toilets all now having signs on the doors. 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. Another requirement was made at the last inspection for weekly checks to be carried out for all essential health & safety checks throughout the home; both the fire alarm testing and checks at each bath and shower outlet had not been undertaken in the two weeks prior to the inspection visit. At this inspection the Registered Manager showed the Inspector the record books for both these weekly checks. Weekly fire alarm testing has been carried out as required and checks on each of the four boiler outlets which each provide different areas of the home with hot water have also been checked. However not all the hot water taps are being checked weekly and so it is still a requirement that a system similar to that discussed with the Registered Manager is devised so that there can be surety that all the hot water taps/ outlets have been checked at least once every month and full records made of these checks including details of what tap was checked when and what the temperature actually was recorded as being at the time of the check. St Mary`s Lodge DS0000007144.V320104.R01.S.doc Version 5.2 Page 21 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 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 support-railed pathways. The garden, with a few rose bushes and shrubs, has not received a lot of attention, especially throughout the winter months; this area should be developed into a far more attractive - and functional - area for the benefit of service users. 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. 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. 10 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. 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 laid down however the floor at the rear of the washing machines needs to be thoroughly cleaned and tidied up. This is a requirement. St Mary`s Lodge DS0000007144.V320104.R01.S.doc Version 5.2 Page 22 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 from evidence gathered both during and before the inspection 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. At present the number of staff who have received NVQ training needs building upon and when the Manager has achieved the target of his staff enrolling on this training and gaining the NVQ qualification then service users will be able to be assured that they are in safe hands at all times. 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. St Mary`s Lodge DS0000007144.V320104.R01.S.doc Version 5.2 Page 23 EVIDENCE: Standard 27 – At the start of this inspection the Inspector was provided with a staffing rota for St. Mary’s by the Registered Manager. 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 - evening shifts. The rota provided supported this statement. Given that that there are 39 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 3 staff on duty overnight – 2 waking staff and 1 sleeping in staff member. Also that there is always a Manager on 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 staff bank numbers around 15 care staff in total including senior carers but excluding the Manager and Deputy Manager. Of these 15 care staff 3 hold an NVQ level 2 qualification and 2 other staff are Registered Nurses. The Inspector explained to the Manager that by next year all care staff would need to be NVQ qualified to at least level 2. The Manager said that those staff that are not at present qualified to this level would be enrolled onto the next NVQ courses so as to achieve the target required. 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. On the files inspected satisfactory the Inspector saw evidence that this process is being properly implemented. St Mary`s Lodge DS0000007144.V320104.R01.S.doc Version 5.2 Page 24 Contracts with staff were also seen on the staffing files and the 3 care staff interviewed all confirmed that they hold a copy of their contracts of employment with St. Mary’s. Standard 30 - 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 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 now 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. Following the discussion at supervision it is also recommended that the Manager provide each and every one of the staff at St. Mary’s with a staff file of their own and which contains copies of the key procedures discussed with them, a copy of their job descriptions and of their contract of employment as well as a copy of their supervision meeting records. This should assist staff to fully understand the homes policies and procedures and to be completely clear about their roles and functions within the unit. St Mary`s Lodge DS0000007144.V320104.R01.S.doc Version 5.2 Page 25 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): Standard 31, 33, 35 & 38. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the inspection visit to this service. 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. St Mary`s Lodge DS0000007144.V320104.R01.S.doc Version 5.2 Page 26 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. 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. He has a sense of direction and leadership. His partner, Mrs Dudhee, is also clearly capable of handling issues at a higher level. She can capably handle meetings (such as service user’s reviews) when necessary. The proprietor has worked to a five-year business plan that guides the spending and development of the home (used as part of the RMA training Course). The proprietor assured the inspector that there is no question that the home is financially viable; occupancy has been maintained reasonably well; mostly the home is close to 100 occupancy. Standard 33 – The Manager showed the Inspector a very comprehensive Quality Assurance file which when fully and consistently operated will ensure that St. Mary’s has one of the very best quality assurance processes. This was discussed in details with the Manager who agreed that at present only partial implementation of the process has been achieved. The Manager has also agreed to implement the unused elements of the process as soon as possible. The Manager showed the Inspector surveys that had been sent out to service users and their relatives and since returned. This information needs now to be analysed and used together with other feedback sources (full detailed in the manual) to inform an annual development and improvement plan. It is a requirement now that the QA policy be now fully implemented. St Mary`s Lodge DS0000007144.V320104.R01.S.doc Version 5.2 Page 27 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. 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 on 10th June 2006 and this is due to be reviewed in December 2006. The policies and procedures manual includes polices on health and safety, risk assessment, moving and handling and fire and all staff have been trained over the last year in the following areas: • 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 – 14.3.06 2. Electrical system check – 12.6.06 3. Lift – 2.4.06 4. Fire alarms – 2.4.06 5. Emergency lighting system – 1.11.06 6. Fire fighting equipment – 18.5.06 7. Water check for legionella organisms – 12.6.06 The proprietor was again advised to have a ‘good clear out’ – archiving the many previous years’ documentation, and ordering more clearly the present years papers. 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 carefully archived. St Mary`s Lodge DS0000007144.V320104.R01.S.doc Version 5.2 Page 28 Records were seen and checked by the Inspector as satisfactory for: 1. Weekly fire alarm tests last tested w/b 20.11.06 2. Staff fire drills every 2 months 3. Fire extinguishers visually checked monthly St Mary`s Lodge DS0000007144.V320104.R01.S.doc Version 5.2 Page 29 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 2 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 X X 3 St Mary`s Lodge DS0000007144.V320104.R01.S.doc Version 5.2 Page 30 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 OP25 Regulation 13(4) Requirement Regular checks of the maximum temperature outflow from all the hot water outlets must be undertaken, with specific records of each test kept. Timescale for action 20/12/06 2. OP26 23(2)d 3. OP30 18(1) 4. OP33 24 The laundry area is well laid out 30/01/07 and there is an impermeable floor laid down however the floor at the rear of the washing machines needs to be thoroughly cleaned and tidied up. This is a requirement. Policies and procedures - staff 01/03/07 must sign to confirm that they have read all relevant documents individually signing and dating against such an indexed format. The Quality Assurance policy 01/03/07 should now be fully implemented. St Mary`s Lodge DS0000007144.V320104.R01.S.doc Version 5.2 Page 31 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 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 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. That the rear garden area is reviewed and made more accessible and attractive to encourage the movement of service users outside and to encourage appropriate and beneficial exposure to sunlight. 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. Social entertainment programme should be expanded to take into account the views of the residents as to what is needed in order to do so. 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 and it was agreed that further discussion needs to be had with staff in the supervision process. All care staff will need to be NVQ trained to level 2. Staff should be provided with files containing key policies and procedures for the unit, JDs, supervision notes and a copy of their contracts. 2. OP8 3. OP19 4. OP37 5. 6. OP12 OP18 7. 8. OP28 OP30 St Mary`s Lodge DS0000007144.V320104.R01.S.doc Version 5.2 Page 32 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. Extracts may not be used or reproduced without the express permission of CSCI St Mary`s Lodge DS0000007144.V320104.R01.S.doc Version 5.2 Page 33 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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