CARE HOME ADULTS 18-65
Alma Lodge 15/17 Alma Road Sheerness Kent ME12 2NZ Lead Inspector
Graham Cummings Unannounced Inspection 15th November 2005 09:30 Alma Lodge DS0000024093.V262552.R01.S.doc Version 5.0 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 Alma Lodge DS0000024093.V262552.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. 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. Alma Lodge DS0000024093.V262552.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Alma Lodge Address 15/17 Alma Road Sheerness Kent ME12 2NZ 01795 669824 01795 669824 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) Mr Jean-Philip Pinagapany Care Home 11 Category(ies) of Learning disability (11) registration, with number of places Alma Lodge DS0000024093.V262552.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 5th July 2005 Brief Description of the Service: Alma Lodge is a home for people with severe Learning Disabilities. The Home can accommodate up to 10 service users. The Home is a house that has been converted and is on several floors. The Home does have a lift for those who have mobility problems. There is a small garden to the rear with a building, which is accessible to the service users and is well maintained. The Home itself is in Sheerness very close to the sea front, it’s in walking distance of the Town Centre, which affords some High Street stores. The Home is also within walking distance of a bus route and a short ride from the main line railway station. There is parking available in the street outside the home. The Home has no offroad parking. Alma Lodge DS0000024093.V262552.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. Graham Cummings carried out an Unannounced Inspection on the 15th November 2005. The Inspector arrived at 09:30 and left at 11:30am. The Inspector spoke briefly with the Manager and Team Leader as they were interviewing 8 people throughout the day. The Inspector explained that the focus of the Inspection would be to look at the homes medication and finance policies and routines as most of the other areas had been covered in the previous inspection. The Manager arranged for the Senior on duty Sarah Brown to assist with the Inspection. The Announced inspection was carried out in July 2005, there was one Requirement regarding Supervision, this is being addressed and staff have now started to receive supervision at more regular intervals although not fully up and running the system in place is progressing well. Following the departure of the Deputy Manager a new management structure is in place, this is Manager, Team Leader and 4 Seniors, the Manager and Deputy have picked up the majority of the Deputies role and had little to no effect on the Seniors or Support Workers. The Inspector looked at Staff supervision, medication and Residents finances. The Inspector left with no concerns regarding the running of the home. What the service does well: What has improved since the last inspection?
The introduction of staff supervision on a regular basis has been implemented, although not fully operational the structure is now in place for all staff to receive a minimum of 6 supervisions a year. A Residents bedroom has been fitted with a new sink. Training in Manual Handling and Health and Safety have been held and Fire training is being arranged. Alma Lodge DS0000024093.V262552.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Alma Lodge DS0000024093.V262552.R01.S.doc Version 5.0 Page 7 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 Outcomes Statutory Requirements Identified During the Inspection Alma Lodge DS0000024093.V262552.R01.S.doc Version 5.0 Page 8 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 the following standard(s): 1,2 Information is available for prospective users to make an informed choice. All prospective users needs are assessed prior to admission. EVIDENCE: A new Pre Admission assessment form is now in place that should ensure the home only takes placements of individuals whose needs can be met. The homes Statement of Purpose and Service User Guide reflect the service being offered. Alma Lodge DS0000024093.V262552.R01.S.doc Version 5.0 Page 9 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 the following standard(s): 6 Residents have individual care plans that are evaluated. EVIDENCE: Individual care plans were in place and were viewed during the last inspection, the Inspector looked at risk assessments that included medication, these were well detailed and included protocols and procedures for individuals who were diagnosed with epilepsy and diabetes. Alma Lodge DS0000024093.V262552.R01.S.doc Version 5.0 Page 10 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 the following standard(s): 12,13,14,15 Residents are able to take part in appropriate activities. Residents are part of the local community. Residents engage in appropriate leisure activities. EVIDENCE: The Inspector was informed that Residents participate in appropriate activities and go out into the local and wider community, since the last inspection Residents have visited the Theatre, zoo, local pub, shops and walks along the beach. Families are encouraged to visit but are asked to call if they are visiting during the day as the Residents are often out during the day. On the day of the inspection 1 Resident was attending college with a member of staff, 4 were going out for lunch, 1 was at the Crawford Day centre and 4 were staying in house to participate in arts and crafts and massage. Alma Lodge DS0000024093.V262552.R01.S.doc Version 5.0 Page 11 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 the following standard(s): 19,20 Residents physical and emotional health care needs are met. No Resident selfmedicates. EVIDENCE: The Inspector looked at medication storage, administration, and policies and procedures. There were 2 locked medication cupboards fixed to a wall and a locked drug fridge, there was only one set of keys available to staff on duty and these are held by the Senior on duty at all times. The Policies and Procedures are all kept in the front of the medication record book. These had been evaluated apart from one, the inspector was informed that this would be addressed within the week. The names and signatures at the front of the file stating who was allowed to dispense medication was out of date and included staff who had left but did not include new staff who were dispensing, the Inspector was told that this again would be addressed within a week. The cupboards were clean and the medication stored in individual containers with lids and the Residents name clearly marked on them. Medication is dispensed by 2 staff to 1 Resident at a time, one being the Senior on duty. The medication is put into a pot with a lid by the Senior and taken to the individual Resident, the Medication Administration Record is signed when the medication has been seen to be taken, the pot and lid is then washed and dried. The Team Leader is responsible for the ordering and checking of the medication. The Inspector looked at the records and found them to be complete.
Alma Lodge DS0000024093.V262552.R01.S.doc Version 5.0 Page 12 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 the following standard(s): 23 Residents are protected from abuse. EVIDENCE: The Inspector looked at the record of 4 Residents finances. The record keeping was clear and up to date with each transaction recorded as follows; when any money is taken from a Residents cash box it is deducted on the record sheet with date and signature, any money not spent is then entered back on the record sheet again with date and signature. The Inspector checked the balances on the record sheet against the cash in the tins and found them to be correct. Alma Lodge DS0000024093.V262552.R01.S.doc Version 5.0 Page 13 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 the following standard(s): EVIDENCE: These Standards were fully covered in the announced inspection in July 2005 and were not Inspected during this visit. Alma Lodge DS0000024093.V262552.R01.S.doc Version 5.0 Page 14 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,34,36 Residents benefit from the clarity of staff roles. An effective staff team supports residents. The homes staff recruitment process protects residents. Staff are supported and supervised. EVIDENCE: Staff have clear guidelines about their job role and responsibilities which are set out in their job description. Over the last 4 months some changes have been made to the Management structure, the Deputy left and it was decided that the Manager/ Provider and Team Leader would take on some of the responsibilities which meant that communication improved and the Seniors in post took on the responsibilities set out in their job description. On the day of the inspection the Manager and Team Leader were interviewing 8 applicants and a further 9 applicants on Thursday for 3 vacant positions of support workers caused by maternity leave. The Inspector looked at staff files and found that supervision had started but was not fully up and running, the Manager and Team Leader are working hard to fully implement the supervision program. Alma Lodge DS0000024093.V262552.R01.S.doc Version 5.0 Page 15 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,42 Residents benefit from a well run home. The health, safety and welfare of Residents are protected and promoted. EVIDENCE: The home is well run and all decisions made in the running of the home take into account individual Residents health, safety, welfare. Alma Lodge DS0000024093.V262552.R01.S.doc Version 5.0 Page 16 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 3 3 X X X Standard No 22 23 Score X 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X X X Standard No 24 25 26 27 28 29 30
STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score 3 X 3 3 X 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Alma Lodge Score X 3 2 X Standard No 37 38 39 40 41 42 43 Score 3 X X X X 3 X DS0000024093.V262552.R01.S.doc Version 5.0 Page 17 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard 20 Regulation 13(4)(c) Requirement The Registered person shall ensure that – unnecessary risks to the health and safety of service users are identified and so far as possible eliminated in that staff signatures for the administration of medication is fully updated and all policies and protocols are evaluated yearly Timescale for action 22/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard 36 Good Practice Recommendations The home continue to implement the staff supervision program to ensure that all staff are supervised a minimum of 6 times per year. Alma Lodge DS0000024093.V262552.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Kent and Medway Area Office 11th Floor International House Dover Place Ashford Kent TN23 1HU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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