Inspection on 09/08/05 for 85 Lodge Lane

This inspection was carried out on 9th August 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

85 Lodge Lane 07/08/07

85 Lodge Lane 14/12/06

85 Lodge Lane 10/10/05

85 Lodge Lane 11/01/05

85 Lodge Lane 13/04/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 85 Lodge Lane Low Town Bridgnorth Shropshire WV15 5DF Lead Inspector Rebecca Harrison Unannounced 9th August 2005 09:55 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. 85 Lodge Lane E56 S20724 Lodge Lane V220168 UAI 090805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 85 Lodge Lane Address Low Town, Bridgnorth, Shropshire, WV15 5DF Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01746 766832 01746 766832 MacIntyre The manager Ms Jo-Anne Jones is not yet registered with the CSCI. Care Home 5 (2) (3) Category(ies) of Learning Disability registration, with number Physical Disability of places 85 Lodge Lane E56 S20724 Lodge Lane V220168 UAI 090805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: No conditions of registration apply. Date of last inspection 11th January 2005 Brief Description of the Service: 85 Lodge Lane is a semi-detached property situated on a residential estate on the outskirts of Bridgnorth, Shropshire. The property is owned by Shropshire Health Authority. MacIntyre is a voluntary organisation contracted to provide a care service. The home is registered with the Commission for Social Care Inspection (CSCI) to provide accommodation and personal care to a maximum of five adults with a learning disability and physical disability. Service users are provided with a single room. Bedrooms for individuals with mobility difficulties are situated on the ground floor. The property is in keeping with the local community. 85 Lodge Lane E56 S20724 Lodge Lane V220168 UAI 090805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. 85 Lodge Lane is a home for people with learning disabilities registered with the Commission for Social Care Inspection to provide accommodation and person care for five adults with a learning disability. The home is a semidetached property situated on a residential estate on the outskirts of Bridgnorth, Shropshire. Shropshire Health Authority owns the property and MacIntyre are contracted to provide a care service. The inspection was unannounced and commenced at 09.55 a.m. and lasted five hours. The inspection was carried out by talking to service users, the manager, the staff on duty, observing activity in the home, examination of records and case tracking. The service users, manager and the staff on duty were most welcoming and co-operated fully throughout the inspection. The purpose of this unannounced inspection was to review the progress made by the home since the last announced inspection undertaken on the 11th January 2005. Fourteen requirements and four recommendations were made. This unannounced inspection identified that only three requirements one recommendation had been met in full. No complaints have been referred to the Commission of Social Care Inspection since the service was last inspected. There have been no referrals made to adult protection. Ms Jo Jones took up the post of manager on 4th January 2005. She has not yet formally submitted an application to the CSCI to become the registered manager of the home. This must be done as a matter of urgency. Ms Jones is line managed by Ms Maria Tole who has replaced Ms Margaret Jukes, Service Manager. Ms Tole must also formally apply to the CSCI to become the Responsible Individual. What the service does well: The staff team are committed and work positively and enthusiastically within the current resources available. The working relationships developed between the service users and staff is excellent and staff clearly have a good knowledge of individual likes, dislikes and interests. Staff appear committed to their roles and providing the people accommodated at the home with a quality service within the resources available. One member of staff stated ‘The home gives 100 care’. 85 Lodge Lane E56 S20724 Lodge Lane V220168 UAI 090805 Stage 4.doc Version 1.40 Page 6 There is evidence of good Multi disciplinary working taking place on a regular basis. Care records seen and discussions held evidence that the health of the individual service users is closely monitored and referrals made to the relevant professionals as and when required. Service users are supported and encouraged to keep in contact with their families and friends and are provided with a comfortable environment to live. What has improved since the last inspection? What they could do better: The health, safety and welfare of the service users and staff must be promoted and safe working practices put into place, which are regularly reviewed and updated. Risks assessments need further development for all of the people accommodated at the home in addition to the development and implementation of health and safety and moving and handling assessments. Medication procedures need to be reviewed to safeguard service users. The opportunities for service users to access leisure facilities and activities in the community after 3p.m. are severely restricted due to the staffing levels currently provided. Feedback gained from one member of staff indicated that if staff were to do less cleaning, greater opportunities for service users to partake in activities and one to ones would be achieved. Discussions held with staff on duty indicated that higher staffing ratios of afternoon and evenings are required. The lack of staff training and understanding of adult protection issues potentially places service users at risk. Record keeping systems in the home need to be significantly improved to ensure continuity of care for the people receiving a service. Information needs to be reviewed to ensure it is up to date as some information still refers to previous management arrangements. 85 Lodge Lane E56 S20724 Lodge Lane V220168 UAI 090805 Stage 4.doc Version 1.40 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. 85 Lodge Lane E56 S20724 Lodge Lane V220168 UAI 090805 Stage 4.doc Version 1.40 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection 85 Lodge Lane E56 S20724 Lodge Lane V220168 UAI 090805 Stage 4.doc Version 1.40 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 and 5 Appropriate procedures are in place that would enable the successful admission of new service users to the home. EVIDENCE: There have been no admissions or discharges since the home was last inspected on 11th January 2005. The home currently has no vacancies. Information is available about the home through the Statement of Purpose and Service User Guide these were last updated in June 2004. These documents need to be reviewed to reflect the new management arrangements for the service. Contracts between the home and each service user were seen on the two care files scrutinised; however these need to be updated. 85 Lodge Lane E56 S20724 Lodge Lane V220168 UAI 090805 Stage 4.doc Version 1.40 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,8 and 9 The staff have a good understanding of the service users’ support needs, however record keeping systems must be significantly improved to ensure the staff have the relevant information for care delivery and risk management; which are regularly reviewed and updated. EVIDENCE: Two care files were selected by the inspector. A Community Care Assessment was seen on the file of the person most recently admitted to the home on 16.07.04. There was evidence that the person had been reviewed by Shropshire County Council on 20.10.04 in line with a minimum three-month ‘settling in’ period as required by National Minimum Standard 4.3. A further review took place on 21.04.05. It was reported that the service user has settled into the home very well. The care plan was seen for another service user dated July 2005. The manager reported that this had been developed by the person’s Link Worker using the person centred approach. The plan overall was comprehensive however, some areas need to be more descriptive to ensure the staff have the information to deliver the care in a consistent manner. 85 Lodge Lane E56 S20724 Lodge Lane V220168 UAI 090805 Stage 4.doc Version 1.40 Page 11 The manager reported that a review was held by Shropshire County Council on a further service user on the 17th May 2005 however the minutes of the review was not available for inspection. It was reported that the other two people resident at the home had not been reviewed since the last inspection and neither had their care plans. Service users are provided with a designated Linkworker. Linkworker days have been scheduled for September and these were identified on the staff duty rota seen during the inspection. The organisation have recently introduced a ‘Monthly Linkworker Checklist Form’ whereby the designated Linkworker is responsible for completing a monthly summary to include updating an individuals care plan, health, risk assessments, holidays, family contact etc. Information leaflets of two independent advocacy services were seen during the inspection. The manager reported that she has approached an independent advocacy service to assist service users with decision-making, however she is still waiting for an advocate to be appointed to the home. It was reported that family members advocate on the behalf of service users. A friend of one service user has visited the home and represents her. Service users’ are unable to manage their own finances. Financial records for the two service users case tracked were seen by the inspector and corresponded with the monies held at the home. The home has robust financial procedures in place and monies are checked at shift handovers. All but one service user have their own bank account. The manager stated that she is currently organising this. See standard 22. Due to the complex needs of the individuals residing at this home, it would be difficult for the current service users to contribute to the development and review of policies, procedures and services. Requirements in relation to this have been made at previous inspections of the home for service users involvement to be enabled in the development and review of the policies and procedures, statement of purpose etc through the use of advocates. The manager reported that she has not yet had the opportunity to look at alternative ways in which to facilitate this at the moment. Requirements have been made at previous inspections in relation to risk assessments. Discussions held with the manager and records seen evidence that only assessments have been undertaken for one individual since the last inspection. An immediate requirement was served at the end of the inspection for the manager to take immediate action to safeguard service users and staff in addition to a letter of serious concern sent to the manager on the following day. 85 Lodge Lane E56 S20724 Lodge Lane V220168 UAI 090805 Stage 4.doc Version 1.40 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14 and 15 Links with the community are good and enrich service users’ social, educational and leisure opportunities. In-house activities require further development and structure. Service users are supported and encouraged to keep in contact with their families and friends. EVIDENCE: Due to the service users complex needs none of the people residing at the home access paid or voluntary work. One service user case tracked is provided with additional funding from the placing authority to provide opportunities for the service user to interact with people of her own age. The person accesses Telford College twice weekly and is currently attending summer activities at the college until the new term commences in September 2005. College reports were seen on the service users file; which indicate that the individual is benefiting from accessing college activities. The service user also accesses local authority day service provision two days per week. 85 Lodge Lane E56 S20724 Lodge Lane V220168 UAI 090805 Stage 4.doc Version 1.40 Page 13 The service users living at Lodge Lane continue to be part of their local community and maintain positive neighbouring relationships. Service users have access to local transport and the transport provided through the home. The home obtains information and advice about local activities, support services and resources available. The manager reported that the staff team are flexible in supporting people out in the local community. Feedback received from staff evidence that service users lead active lives and access a variety of leisure activities within the community. During the inspection four people went on a trip to Dunmaster Hall, near Kidderminster. An activity timetable for all the service users was seen on the daily file. It was acknowledged by the manager that the information requires updating. Records seen on the service user files case tracked evidence that individuals have been to a BBQ, meals out, shops, multi-sensory, picnics, hydrotherapy, theatre and day trips. Service users have either been on holiday or have holidays planned. Trips out are being provided to one person as it is considered that it would not be in her best interests to access a holiday. A ‘Planning Your Holiday’ form was seen however these have not been completed nor have risk assessments for the holidays taken or planned. Staffing ratios after 3pm decrease to two staff on duty supporting five service users. Discussions held with the manager and staff on duty evidence that opportunities for service users to access leisure facilities and activities in the community after 3p.m. are severely restricted due to the staffing levels currently provided. In-house activities are not currently recorded, however the manager intends to implement this. A requirement has been made under standard 33 in relation to staffing. Discussions held with the manager indicate that family links continue to be promoted. Family and friends are welcome to visit the home at any reasonable time and that people maintain contact through telephone calls, letters and visits. A contacts log is maintained on service user records. Service users are provided with opportunities to meet people who do not have a disability. The home has a visitor’s book in place, which is well maintained. 85 Lodge Lane E56 S20724 Lodge Lane V220168 UAI 090805 Stage 4.doc Version 1.40 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19,20 and 21 The personal and health care needs of the service users are well met with evidence of good multi-disciplinary working taking place on a regular basis. Medication procedures must be reviewed to safeguard service users. EVIDENCE: Care records seen and discussions held evidence that the health of the individual service users is closely monitored and referrals made to the relevant professionals as and when required. All of the service users have designated Linkworkers for continuity of care. Personal care is provided in the privacy of service users own rooms or bathrooms. Service users have the technical aids and the equipment they need for maximum independence. A letter was seen on one file from the senior support worker advocating on behalf of a service user in relation to his broken wheelchair and the delay in getting this repaired. A letter from the wheelchair services has very recently been received apologising for the delay. Discussions held with the manager confirmed that the physiotherapist is visiting the home with a replacement chair. Records seen evidence that technical aids and equipment are determined by professional assessment. 85 Lodge Lane E56 S20724 Lodge Lane V220168 UAI 090805 Stage 4.doc Version 1.40 Page 15 Service users are enabled and supported to access local NHS healthcare facilities. All of the service users are registered with the local medical practice. Appointments and outcomes are documented. Health profiles were seen on the files reviewed. These documents are currently incomplete however the manager reported that they require the support of families to complete the comprehensive documents and that these will be completed for all service users as soon as possible. None of the current service users’ are able to manage their own medication. It was reported that four service users are prescribed medication in addition to one person who requires diet supplements. No controlled drugs are currently prescribed to the people living at the home. A record of current medication is maintained on service users’ files. Examination of medication administration records identified a number of gaps whereby medication had not been recorded on 27.07.05. and a couple of gaps were seen on other dates. This was immediately brought to the manager’s attention in addition to Stesolid Rectal diazepam, which had just expired on 07/05. The manager reported that she is in liaison with a college in relation to providing the staff with accredited training in the safe handling and administration of medicines. It was reported by the manager that the new senior support worker has recently taken on the responsibility of medication for the home and has a good knowledge of medicines and has received training through her previous employer. The homes policy and procedures relating to medication was not reviewed at this inspection. The home has guidelines in place for the Death of a Service User and wishes in the event of death were seen on file. Questionnaires have been sent to the families of service users in the event of the death of the person in care. The manager stated that not all of these have been returned. It is acknowledged by the CSCI that the matter is very sensitive. The home has previously experienced and managed the deaths of two service users in a very professional manner supporting the families concerned, staff and service users. 85 Lodge Lane E56 S20724 Lodge Lane V220168 UAI 090805 Stage 4.doc Version 1.40 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 The home has a satisfactory complaints procedure in place that has been produced in a pictorial format. The lack of staff training and understanding of adult protection issues potentially places service users at risk. EVIDENCE: The home has a policy and procedure for dealing with complaints; which is also displayed in a pictorial format in the reception area of the home. The complaints procedure requires updating to reflect the new name of the regulatory body. A requirement under standard 41 has been made in relation to records. It was reported that the home has not received any formal complaints since the last inspection and there were no entries recorded in the complaints book held at the home. No complaints have been referred to the Commission for Social Care Inspection. No referrals have been made to Adult Protection since the last inspection of the home. A copy of the local Multi-Agency Adult Protection Policy and Procedures were seen in the office however discussions with staff on duty evidenced that they did not have a knowledge of the local policy or procedures and have not received training in the local adult protection procedures. As previously stated in standard 7, service users require assistance with the management of their finances. Records seen and discussions held indicated that the procedures for the management of finances appear robust. 85 Lodge Lane E56 S20724 Lodge Lane V220168 UAI 090805 Stage 4.doc Version 1.40 Page 17 ‘Finance Guidelines for the People We Support’ dated 1997 and ‘Guidelines to support service Users in the Management of their Bank Account’ dated 1999 require updating. It was reported that none of the service users accommodated at the home are ever subject to physical restraint. The manager reported that a number of staff have received training in physical intervention (TPI). 85 Lodge Lane E56 S20724 Lodge Lane V220168 UAI 090805 Stage 4.doc Version 1.40 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) x EVIDENCE: The intended outcomes for Standards 24 – 30 were not reviewed on this occasion. No requirements or recommendations were made in relation to the environment as a result of the previous inspection of this service. 85 Lodge Lane E56 S20724 Lodge Lane V220168 UAI 090805 Stage 4.doc Version 1.40 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33 and 36 The staff team are committed and work positively and enthusiastically within the current resources available. Increased staffing levels would provide greater opportunities and improve service users whole quality of life. EVIDENCE: Observations made throughout the inspection indicate that staff respect service users and are good listeners and communicators. The staff on duty appeared motivated and committed to providing a quality service to the people in their care. Discussions held and records seen indicate that the team have developed good professional relationships with health and social care professionals. It was reported by the manager that nine staff hold an NVQ qualification in care. Certificates were not seen at this inspection. The manager reported that no one under the age of 21 is currently employed by the home. The team at Lodge Lane consist of a Head of Service, a senior support worker and nine support staff. The home does not employ domestic or catering staff and therefore care staff are expected to undertake these duties in addition to their care role. Staff spoken with stated that these duties do not infringe on the quality of the care provided to the people in residence however additional staffing particularly in the afternoon and evening would provide service users with greater opportunities to partake in structured activities. 85 Lodge Lane E56 S20724 Lodge Lane V220168 UAI 090805 Stage 4.doc Version 1.40 Page 20 The duty rota seen in addition to discussions held with the staff and manager indicate that the ratios of staff to service users is 4:5 until 3 p.m. and then 2:5 until 10p.m. The night staffing arrangements consist of one waking night member of staff and one member of staff sleeping in. Discussions held and observations made evidence that the dependency levels of the people accommodated at the home are high. Therefore staffing levels must be reviewed to ensure staffing meets the individual needs of the service users and provides opportunities for service users to access leisure activities in the community of an afternoon and evening and to ensure the safety of the service users and the staff team. The manager reported that a high use of agency staff were used throughout July due to staff taking annual leave, however core agency staff were used. It was reported the next team meeting is scheduled for 17.08.05 and this was seen recorded on the duty rota. The manager reported that the home currently has no vacancies. A requirement was made at the previous inspection for all staff to receive a minimum of six supervisions per year covering all aspects of NMS 34.4. and for all staff to have an annual appraisal with their line manager to review performance and agree a career development plan. The manager stated that she is working towards meeting these requirements. Ms Jones stated that the new senior support worker is to undertake training and will commence supervising staff from January 2006. An entry was seen recorded in the Communication Book detailing dates for supervision sessions throughout August and September. The manager reported that she is due to undertake training on PDP’s (appraisals) on 10.08.05 in preparation to commence staff appraisals. 85 Lodge Lane E56 S20724 Lodge Lane V220168 UAI 090805 Stage 4.doc Version 1.40 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,39,40,41,42 and 43 The manager has an understanding of the areas in which the home needs to improve. The Health, safety and welfare of service users and staff are not fully promoted by the current working systems in place potentially placing service users and staff at risk. EVIDENCE: Ms Jo Jones is the Head of Service and commenced working at the home on 04.01.05. Ms Jones is yet to submit her application to the CSCI to become the registered manager of the home. This application must be submitted as a matter of urgency. As part of the CSCI registration process it will be ascertained as to whether Ms Jones has the necessary qualifications and experience to manage the home. 85 Lodge Lane E56 S20724 Lodge Lane V220168 UAI 090805 Stage 4.doc Version 1.40 Page 22 Ms Jones is line managed by the Ms Maria Tole. The manager reported that her appraisal is booked for 10.08.05. Discussions held with Ms Jones indicated that she has not yet commenced the Registered Managers Award or the NVQ level 4 in Care. These qualifications must be obtained by 31.12.05. The manager is contracted to work 37 hours per week. The duty rota evidenced that the manager is flexible with her hours and covers the occasional weekend. It is MacIntyre’s policy that all managers have 19.5 hours to fulfil management duties and19.5 hours for providing direct care. A new senior support worker has recently been appointed and it is envisaged that she will support the manager with her administration duties however; the senior support worker is currently not allocated admin time. It is recommended that this be reviewed to ensure that the manager has sufficient time and support to fulfil the role and responsibilities of a registered manager. The manager stated that she feels well supported by her new line manager, receives regular supervision and has recently passed her six-month probation. The requirement made at previous inspections for the views of families, friends, advocates, service users and professionals to be sought in relation to the service provided has been actioned with the manager collating the feedback from ‘Investing In Care’ questionnaires sent out on 17.11.04. Although not all questionnaires have been returned the feedback was generally very positive in relation to the service. The manager stated that questionnaires are due to be sent out again in September 2005 and information will be collated. Ms Maria Tole has taken over from Ms Margaret Jukes as the Service Manager and is to formally apply to the CSCI to become the Responsible Individual. Ms Tole is responsible for conducting unannounced Regulation 26 visits to the home. One report dated 23.05.05 was seen on file. It was reported that Ms Tole has also undertaken visits in June and July however a copy of the reports were not on file and no reports have been received by the CSCI. Previous inspections have highlighted a need for policies and procedures to be developed and reviewed on topics outlined in Appendix 2 (2nd edition of the NMS, Care Homes for Adults 18-65) and that these are specific to the home. Policies and procedures are held in the office. The organisation provides corporate policies and procedures and these are well presented and organised in separate files containing ‘General Polices and Procedures’, ‘Supporting Service Users Policies’ and ‘Human Resources Policies’. As previously stated a number of policies and procedures require updating. The manager has recently produced guidelines, which are service specific, and these were seen at the inspection. 85 Lodge Lane E56 S20724 Lodge Lane V220168 UAI 090805 Stage 4.doc Version 1.40 Page 23 Since the last inspection the manager has re-organised the office. She reported that the home is soon to have a computer, which will aid the maintenance of record keeping generally. Throughout this report it is identified that a number of records require implementing or updating. Three requirements and one recommendation were made at the previous inspection in relation to health and safety. The manager reported that first aid training for the relief member of staff has been booked for September. However food hygiene for the majority of staff remains outstanding. It is considered that the requirement made for health and safety risk assessments to be developed and implemented for all identified risks has not been met and both service users and staff are currently placed at significant risk. As previous stated an immediate requirement was served at the end of the inspection for the manager to take immediate action to safeguard the service users and her staff team. The requirement made in relation to the testing of portable appliances was met on 24.01.05 and records of such were seen on the health and safety file. The Fire Officer visited the home on 14.01.05 and a report of the inspection was seen on file stating that fire procedures were satisfactory. The home has an emergency evacuation plan in place. The home has a Daily Monitoring File which contains the duty rota, important telephone numbers, menu’s, fire, temperature, and daily cleaning checks in addition to on-call rotas. The manager reported that it is the responsibility of the staff member sleeping in to undertake daily fire checks. A list of appointed first aiders was seen displayed in the laundry room. The manager stated that eight staff undertook the appointed persons one day training in July and five more staff are booked on the training for September. The majority of food hygiene certificates are out of date. The manager reported that two staff was undertaking moving and handling training on the afternoon of the inspection. The home has a Health and Safety Manual in place dated 2003 and staff are requested to sign to say that they have read and understood the manual. However, this has not been signed by all of the current staff. Service certificates were in place for the servicing of the equipment. COSHH data sheets are in place and a list of COSHH products to be purchased from a particular store however a risk assessment remains outstanding. It was reported that the home has a designated Health and Safety rep. A record of accidents is maintained and it was reported that there have been no Accident and Emergency admissions since the service was last inspected. Standard 43 was not fully assessed on this occasion however it was brought to the managers attention that certificate of insurance displayed outside the office had expired on 05.08.05. 85 Lodge Lane E56 S20724 Lodge Lane V220168 UAI 090805 Stage 4.doc Version 1.40 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 x x x 2 Standard No 22 23 ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 1 3 2 1 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x x Standard No 11 12 13 14 15 16 17 x 3 3 3 3 x x Standard No 31 32 33 34 35 36 Score x 3 2 x x 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 85 Lodge Lane Score 3 3 1 3 Standard No 37 38 39 40 41 42 43 Score 2 x 3 2 2 2 2 E56 S20724 Lodge Lane V220168 UAI 090805 Stage 4.doc Version 1.40 Page 25 Yes Are there any outstanding requirements from the last inspection? 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 1 Regulation 4&5 Requirement The Statement of Purpose and Service User Guide must be updated to reflect the new managerial arrangments. The Service User contract must be updated and produced in a format appropriate to the needs of the people accommodated. Care plans for all service users must be more detailed and contain all aspects of personal, social support and healthcare needs to ensure staff deliver the necessary care required in a consistent manner. Care plans must be reviewed with the service user (involving significant professionals, family and advocates) at the request of the service user or at least every six months and updated to relflect changing needs; and agreed changes are recorded and actioned. Service users involvement must be enabled in the development of and review of the policies and procedures, statement of purpose etc thorough the use of advocates, family etc. Timescale for action 01.10.05 2. 5 5 (b)(c) 01.10.05 3. 6 15 (1) 19.09.05 4. 6 14(2)(a) 15 (2) 01.10.05 5. 8 24 (3) 01.11.05 85 Lodge Lane E56 S20724 Lodge Lane V220168 UAI 090805 Stage 4.doc Version 1.40 Page 26 6. 9 13 (4) (b)(c) Generic and individual risk assessments must be reviewed and updated. New assessments covering both in-house, community activities and holidays must be developed and implemented. 23.08.05 7. 9 13 (4) (b)(c) Risk assessments specific to 23.08.05 each individual must be included in service user files in order for staff to cross reference to service user care plans. Medication must be administered as per the prescribers instructions. All staff resonsible for the administration of medicines must receive accredited training to include all areas of NMS 20.10. Expired medicines must be returned to the pharmacy for disposal. Staff must be provided with training on the local policy and procedures for adult protection. Policies for the management of service users finances must be reviewed and updated. Staffing levels must be reviewed to ensure staffing meets the individual assessed needs of the service users at all times ensuring the safety of the service users and the staff team. Staff must receive a minimum of six supervisions per year covering all aspects of NMS 34.4. Staff must have an annual appraisal with their line manager to review performance and agree a career development plan. The manager must obtain qualifiactions at level 4 NVQ, ib both management and care. With immediate effect 01.10.05 8. 20 13(2) 9. 20 18(1) 10. 11. 12. 13. 20 23 23 33 13 (2) 13 (6) 13,16 18 (1)(a) With immediate effect 01.10.05 01.11.05 19.09.05 14. 15. 36 36 18 (2) 18 01.10.05 01.11.05 16. 37 9 31.12.05 85 Lodge Lane E56 S20724 Lodge Lane V220168 UAI 090805 Stage 4.doc Version 1.40 Page 27 17. 40 12,13,16, 17,18,19 18. 41 17 19. 42 13(4)(5) 23(4)(5) 20. 42 12,13 21. 43 25(2)(e) Policies and procedures must be developed reviewed and amended on topics outlined in Appendix 2 (2nd edition of the NMS, Care Homes for Adults 1865). The manager must ensure these are specific to the home. All records required by regulation for the protection of service users and the effective and efficent running of the home must be maintained, up to date and accurate. All staff must undertake mandatory health and safety training to include moving and handling,first aid, food hygiene, fire safety etc. Health and safety risk assessments and moving and handling assessments must be developed and implemented to ensure safe working practices and staff must be familiar with these processes. A valid certificate of insurance in respect of liability must be obtained. 01.11.05 01.10.05 17.10.05 23.08.05 With immediate effect 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. 2. Refer to Standard 14 33 Good Practice Recommendations it is recommended that in-house activities be developed, structured and recorded. It is recommended that following a review of staffing levels further opportunities be provided for service users to pursue leisure activiites in the community of an evening. 85 Lodge Lane E56 S20724 Lodge Lane V220168 UAI 090805 Stage 4.doc Version 1.40 Page 28 Commission for Social Care Inspection 1st Floor, Chapter House South Abbey Lawn Shrewsbury SY2 5DE National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 85 Lodge Lane E56 S20724 Lodge Lane V220168 UAI 090805 Stage 4.doc Version 1.40 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!