Inspection on 05/05/05 for Alma Lodge

This inspection was carried out on 5th May 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Alma Lodge 03/09/08

Alma Lodge 04/10/06

Alma Lodge 15/11/05

Alma Lodge 22/12/04

Alma Lodge 28/04/04

Alma Lodge 05/12/03

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

CARE HOME ADULTS 18-65 Alma Lodge 15/17 Alma Road Sheerness Kent ME12 2NZ Lead Inspector Graham Cummings Announced 05/07/05 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. Alma Lodge H56-H05 S24093 Alma Lodge V226093 050705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Alma Lodge Address 15/17 Alma Road, Sheerness, Kent, ME12 2NZ 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) 01795 669824 01795 669824 Mr Jean-Philip Pinagapany Registered Care Home 11 Category(ies) of Care Home for Younger Adults with a Learning registration, with number Disability, 11 of places Alma Lodge H56-H05 S24093 Alma Lodge V226093 050705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22/12/04 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 H56-H05 S24093 Alma Lodge V226093 050705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Graham Cummings carried out the Announced Inspection on the 5th July 2005, the Inspector arrived at 09:45 and left at 16:00. The Inspection was carried out through discussion with the Registered Manager Mr Philip Pinagapany, the Deputy Manager Sue Holton and a senior member of staff. The inspector toured the home and looked at care plans, Service User and staff files. The inspector had received prior to the inspection a completed Pre Inspection Questionnaire. Service Users were going out for the day but the Inspector did meet with some of them. The communal areas of the home were clean and well furnished, the main lounge by the front door could benefit from being made more ‘homely’. Service User bedrooms were seen and found to be well furnished and decorated, due to some of the behaviours of individual Service Users their rooms were not as personalised as others. The paperwork seen was of a good standard, the Care Plans were exceptionally well detailed and informative. There were 7 requirements at last inspection in December 2004, all of these have been addressed. The home is run to meet the needs of the Service Users. What the service does well: What has improved since the last inspection? The home has purchased a new van, decorated and brought new furniture for numerous rooms and changed the use of some rooms to improve facilities for Service Users. The Statement of Purpose and Service User guide have been updated, a new needs assessment form and new 6 monthly review forms has been produced. The fire alarm system is now in full working order and a nurse call system is being looked into. The number of staff on duty has increased in line with the last inspection and someone has been appointed to the position of Alma Lodge H56-H05 S24093 Alma Lodge V226093 050705 Stage 4.doc Version 1.30 Page 6 Team Leader and starts on the 25th July 2005. There were no offences odours noted when the inspector toured the home. 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 H56-H05 S24093 Alma Lodge V226093 050705 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Alma Lodge H56-H05 S24093 Alma Lodge V226093 050705 Stage 4.doc Version 1.30 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 standard(s) 2,5 Service Users needs are assessed. Service Users had Statement of Terms and Conditions on their files. EVIDENCE: The Inspector was shown a new format of the needs Assessment form that is going to be used to assess the needs of prospective Service Users. This form consists of 12 pages and covers all the areas that would be required to inform the home whether they could meet the need of the prospective referral. The Inspector looked at 3 Service User files and found that they all had Statements of terms and Conditions. Alma Lodge H56-H05 S24093 Alma Lodge V226093 050705 Stage 4.doc Version 1.30 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 standard(s) 6,7,9 Service Users through Family and Advocates know their assessed needs are reflected in their individual plans. Service Users make decisions where possible. Service users are supported to take risks as part of an independent lifestyle. EVIDENCE: Where Service Users are unable to understand or be involved in planning their care, the home uses family members and/or advocates to carry this out. This scenario also applies to the decision making in Service Users lives. The Inspector looked at 3 Service User files and found the care plans to contain all of the information required to enable a new staff member to carry out tasks for a Service user in a way that met their choice and needs, these had also been evaluated on a monthly basis and were dated and signed. The Inspector was very impressed with the high standard and clarity of information in the care plans. Comprehensive risk assessments relating to the individuals needs were on file, these were evaluated, dated and signed. Alma Lodge H56-H05 S24093 Alma Lodge V226093 050705 Stage 4.doc Version 1.30 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 standard(s) 12,13,15,17 Service Service Service Service users users users users take part in appropriate activities. are part of the community. families have appropriate contact. are offered a healthy diet EVIDENCE: Service users have an activity program that includes horse riding, swimming, pottery visiting the local pub and having meals out and going on day trips to such places as Moat Park in Maidstone and Chessington Amusement Park. The home has become an accepted part of the community, the landlord of the local pub makes the Service users very welcome. Families are welcome to visit the home but are asked to let the home know if possible as they are often out on activities, the home is mixed gender, there are no relationships between any individuals. The Inspector was sent the menu for Service users prior to their visit, there were 3 separate menu’s sent, a general one for the majority, the second one was for 2 service Users and the third for an individual Service User, all consisted of a healthy and nutritious diet. Alma Lodge H56-H05 S24093 Alma Lodge V226093 050705 Stage 4.doc Version 1.30 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 standard(s) 18,19,20,21 Service users receive personal support in the way they prefer. Service users physical and emotional health needs are met. No Service user self medicates. Service users wishes regarding illness and death are handled with respect. EVIDENCE: Service Users receive personal support that has been set out in a very detailed and comprehensive manner and written in the first person. The support starts from the routine of getting up in the morning through to bedtime. The Inspector found the content of the plans to be of a high standard. The home has access to external agencies to advice on different ways that may assist staff to deal with emotional and health issues. None of the Service users are able to self medicate but policies and procedures are in place for this should it ever be needed. On the 3 Service user files looked at by the Inspector all had the wishes of Service users or families stating who to contact in the event of illness or death. Alma Lodge H56-H05 S24093 Alma Lodge V226093 050705 Stage 4.doc Version 1.30 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 standard(s) 22,23 Service users views are listened to. Service users are protected from abuse. EVIDENCE: Most of the Service users living at the home suffer from severe learning disability so their views are not always able to be obtained, when this is the case the home ensures that they have contact with family members and/or care managers to try and ascertain their views. Policies and procedures are in place to protect Service users. Adult protection training for 12 staff took place on the 20/9/04 and it is being arranged for staff who did not attend to attend a course in the near future. Alma Lodge H56-H05 S24093 Alma Lodge V226093 050705 Stage 4.doc Version 1.30 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 standard(s) 24,25,26,27,28,30 Service users live in a comfortable and safe environment. Service user bedrooms meet their needs. Service users bedrooms promote their independence. Bathrooms and toilets provide sufficient privacy to meet individual needs. Communal space supplements Service users individual rooms. The home is clean and hygienic. EVIDENCE: The home is well furnished, comfortable and safe, there are some bedrooms and the lounge by the front door that do not look as homely as other rooms, this is partly due to the behaviours of individual Service users who will pull curtains down and tear pictures and posters, the Inspector discussed this issue with the Manager and they will look at the possibility of looking at alternative ways to make the rooms more homely, this may be by painting murals or stencilling the walls and having laminated posters. The majority of rooms are personalised and promote independence. There are sufficient bathrooms and toilets around the house to meet individual needs. The communal space has been increased with a change of use of some rooms and the building of an extension have meant that the home now has a second lounge/quiet room. The home was clean and free from offensive odours. Alma Lodge H56-H05 S24093 Alma Lodge V226093 050705 Stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,34,35,36 Staff roles are clearly defined. Competent and qualified staff supports Service users. Service users are protected by the homes recruitment policy and practices. Staff are trained to meet the needs of the service users. The staff team is well supported but require formal supervision. EVIDENCE: The staff structure consists of, Manager, Deputy, Team Leader, 4 Seniors, 19 Care staff, cook, domestic and maintenance person. The Inspector looked at two staff files and both contained the relevant job descriptions, references, identification, Criminal Record Bureau checks, contract and detailed application form. The home has an active training program and so far this year 2005, 12 staff have attended each of the following, Adult Protection, Manual Handling, 1st Aid, Health and Safety and Medication. The staff team are well supported and the appointment of a permanent Team Leader who starts on the 25th July 2005 will enable the management team to re-establish a full program of formal supervision. The Manager and Deputy have recently been giving supervision on an informal basis. The staff rota is about to be changed so that there is no handover in the middle of the day as this disrupts full day activities that take place, the staff team have been consulted and are in agreement that this would be beneficial to the Service users. Alma Lodge H56-H05 S24093 Alma Lodge V226093 050705 Stage 4.doc Version 1.30 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 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) 37,38,40,42,43 Service users benefit from a well run home and the leadership and management approach. Policies and Procedures safeguard the Service Users. The health, safety and welfare of Service users are promoted and protected. Service Users benefit from competent and accountable management of the service. EVIDENCE: The home is well managed and the needs of the Service Users are at the forefront of all decisions made in the running of the home. The policies and procedures are in need of being updated and being made more specific to the home, the Manager is in the early stages of starting this process. The health, welfare and safety of Service Users are promoted and protected by the competency of the Management and staff team and through the training that staff attend. The Manager is completing his NVQ 4 in Management. Alma Lodge H56-H05 S24093 Alma Lodge V226093 050705 Stage 4.doc Version 1.30 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 x 3 x x 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 2 3 3 x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 x 3 Standard No 31 32 33 34 35 36 Score 3 3 x 3 3 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Alma Lodge Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x 3 3 H56-H05 S24093 Alma Lodge V226093 050705 Stage 4.doc Version 1.30 Page 17 No 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 36.4 Regulation 18(2) Requirement A record should be kept to evidence that supervision is taking place at least 6 times per year. Records must be kept and include the areas listed in Standard 36.4. Timescale for action Immediate 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 24 and 26 Good Practice Recommendations That the home look at ways to make the lounge by the front door and two of the Service users bedrooms more homely and inviting. Alma Lodge H56-H05 S24093 Alma Lodge V226093 050705 Stage 4.doc Version 1.30 Page 18 Commission for Social Care Inspection 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 © 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 Alma Lodge H56-H05 S24093 Alma Lodge V226093 050705 Stage 4.doc Version 1.30 Page 19 - 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. 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