Inspection on 29/04/08 for Anita Jane`s Lodge

This inspection was carried out on 29th April 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Anita Jane`s Lodge 29/03/10

Anita Jane`s Lodge 14/04/09

Anita Jane`s Lodge 24/11/08

Anita Jane`s Lodge 14/11/07

Anita Jane`s Lodge 09/07/07

Anita Jane`s Lodge 15/06/06

Anita Jane`s Lodge 22/09/05

Anita Jane`s Lodge 12/04/05

Anita Jane`s Lodge 07/10/04

Anita Jane`s Lodge 05/04/04

Similar services:

Trevayler Residential Care Home

Thornham Grove

Thistle Hill Hall

Conifer Lodge

Westwood Lodge

Egerton Lodge Care Home

Alfred Minto House Care Home

St Matthews Unit

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

CARE HOME ADULTS 18-65 Anita Jane`s Lodge 126/128 Uppingham Road Leicester Leicestershire LE5 0QF Lead Inspector Ruth Wood Unannounced Inspection 29th April 2008 01:10 Anita Jane`s Lodge DS0000006432.V363522.R01.S.doc Version 5.2 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 Anita Jane`s Lodge DS0000006432.V363522.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 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. Anita Jane`s Lodge DS0000006432.V363522.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Anita Jane`s Lodge Address 126/128 Uppingham Road Leicester Leicestershire LE5 0QF 0116 276 8071 F/P 0116 276 8071 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) Samalodge Limited Mrs Lois Fletcher Care Home 16 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (16) of places Anita Jane`s Lodge DS0000006432.V363522.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may continue to accommodate a named person who falls within category LD as detailed in variation application number 49808. 14th November 2007 Date of last inspection Brief Description of the Service: Anita Jane’s Lodge is a care home providing care for sixteen adults with mental health difficulties, in addition it provides a respite service (short stay) for up to one service user and offers a day care service. There are eight single and four shared bedrooms all without en-suite facilities, located on the ground and first floor. There are bathing/showering and toilet facilities on both the ground and first floor. Communal areas consist of a lounge and dining room/recreational room and kitchen on the ground floor. Anita Jane’s Lodge has a large rear garden, which incorporates a patio area. Information as to the service offered can be found on site in documents referred to as the Statement of Purpose and Service Users Guide. A copy of the latest published report from the Commission for Social Care Inspection can be found in the entrance lobby. Fees at the home are currently £297 per week. Anita Jane`s Lodge DS0000006432.V363522.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This inspection took place on a weekday between 1:10pm and 4:55pm. As well as this visit, information to inform this report was also drawn from the following sources: • A random inspection of the service lasting 3 hours on 17/01/08 • Information from the Annual Quality Assurance Assessment (AQAA); The AQAA is a self-assessment, that focuses on how well outcomes are being met for people using the service. It also gives us some numerical information about the service. • Discussions with local authorities who commission the service. • Other information from the service such as letters in reponse to requirments made at previous inspections. This visit focused on how three people who live at Anita Jane’s Lodge are supported. Their support plans were looked at and how that support is delivered was discussed with two of them and the two staff members on duty. Medication and health records for these three people were also looked at. Three further people were asked about day-to-day life at Anita Jane’s Lodge and their relationship with the staff team. Staff interaction with people was also observed. The recruitment and training records for three staff were looked at and staff’s experience of training and their knowledge of certain procedures was discussed. A sample of responses from the manager’s recent survey of people who live in the home, staff, relatives and professionals that visit was also seen. The main communal areas of the home were looked at, as well as two people’s bedrooms. What the service does well: The people who live in the home said that they were “settled” and liked living in an area where they had easy access to shops, the park and regular buses to the town. Everyone spoken with said that they liked the food “it’s very nice – it’s improved a lot”. One person was very pleased with their bedroom, which had just been re-decorated and they had chosen the colour scheme. People are generally well supported in having their physical health needs met and staff support them to attend health care appointments and to monitor any ongoing health conditions. Anita Jane`s Lodge DS0000006432.V363522.R01.S.doc Version 5.2 Page 6 The home is clean, all staff have received training in infection control and good practice was observed in this area. Systems and equipment are regularly serviced and staff receive regular training in fire safety, food hygiene, first aid and moving and handling. What has improved since the last inspection? The registered manager and staff team have worked hard since the random inspection in January to address the requirements and recommendations made then and at the two previous key inspections. A copy of the most recent inspection report from CSCI has been made available to people who live or visit the home. Following discussion with the local authorities that commission services from Anita Jane’s Lodge, people are no longer issued with verbal or written warnings in response to behaviour considered to be inappropriate. Any concerns of this nature are immediately referred to the social worker responsible for the person’s placement. Support plans now reflect how people’s needs in relation to their mental health should be met and some people’s risk assessments identify how to respond to specific areas of need, although further improvement is needed in some of these assessments. Likewise some people’s capability to manage their own medication has been assessed but for other people a more detailed assessment is required. Support plans now include information about how people like their personal care needs to be met. How staff are deployed within the home has been reviewed and less time is spent on domestic activities to enable more time to be spent supporting people. A Criminal Records Bureau check has been undertaken for all staff and their names have been checked against the vulnerable adults register. These checks were also completed for a gardener before they started work at the home. A system that enables the people that live in the home to comment on and inform its operation has been initiated. The views of staff, relatives and professionals associated with the service, such as General Practitioners, have also been sought. Staff are receiving training in the conditions associated with mental ill health to enable them to support the people living in the home more effectively. New staff are also receiving an appropriate induction and are not left to work unsupervised or escort people away from the home unaccompanied, until this induction is complete. Anita Jane`s Lodge DS0000006432.V363522.R01.S.doc Version 5.2 Page 7 The lock on the medication cabinet has been repaired meaning that medication can be secured but easily accessed when required. People have been consulted about the décor in the home and attempts have been made to make the environment more ‘homely’ by hanging pictures and changing colour schemes. What they could do better: Staff are to receive training in person-centred care, an approach that places the person at the centre of the care planning process. Following this training, the manager must ensure that staff work with people to ensure that support plans fully acknowledge their views and detail how they can work in partnership with staff to achieve their aspirations. Time must be allocated for staff supervision and discussion to make sure that knowledge gained during training is incorporated into staff’s everyday practice, so that service users are appropriately supported. People who live in the home said that staff were “strict” and the home was “disciplined”. The registered manager must monitor staff’s approach to people who live in the home so that encouraging people to do things for themselves is not translated as staff telling people what to do All people who live in the home must be supported to take reasonable risks and assessments should clearly identify any potential risk and how this may be safely managed. The registered manager and staff would benefit from training in this area. A record must be made of all medication administered, at the time of administration. Information detailing under what circumstances people should be given ‘as required’ medication should be contained within their support plans. This should include who has the authority to administer the medication and the details of the prescribing medical practitioner. Medication no longer needed should be returned promptly to the pharmacist. To make sure that the improvements in management are sustained, the responsible individual (or their representative) must visit the home, unannounced at least once per month and write a report based on their interviews with the people who live there, their representatives (such as relatives) and staff. The premises should also be inspected. A report should also be compiled based on the feedback gathered by the manager who has recently surveyed the opinions of people who live in the home, staff, their relatives and professionals such as GPs. This report should say how their views will inform how the service is run and a copy should be sent to CSCI. Anita Jane`s Lodge DS0000006432.V363522.R01.S.doc Version 5.2 Page 8 The Service Users Guide should be made available in different formats so that it is fully accessible to those people for whom standard written English may be difficult to understand. 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. Anita Jane`s Lodge DS0000006432.V363522.R01.S.doc Version 5.2 Page 9 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 Anita Jane`s Lodge DS0000006432.V363522.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 Quality in this outcome area is adequate People have access to information about the home, which should enable them to make an informed decision about living there. Improvement in assessment means that people’s needs, can be met more effectively. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Assessments from placing authorities were on file for the three people whose support was focussed on. Some assessment of need was also contained within support plans completed by the home’s staff. This included assessments for pressure area care and risk of falls, information not immediately appropriate for this service user group. The template used for support plans is designed for use with older people, which appears to be why such information is routinely completed, whether it is required or not. Support plans and placing authorities’ assessments did contain information about people’s needs arising from their mental ill health. No one has been admitted to the home since the last key inspection, therefore the arrangements for new people to ‘trial’ the home were not assessed. Information gained at a random inspection on 17/01/08 indicated that people were no longer issued with verbal or written warnings in relation to behaviour deemed inappropriate by the manager and staff. Placing authorities had instructed the manager that any such concerns, which may jeopardise the Anita Jane`s Lodge DS0000006432.V363522.R01.S.doc Version 5.2 Page 11 placement, must be referred to them. No evidence of such warnings being given was found at this inspection. Everyone who lives in the home is given a copy of the Service Users Guide in a standard written format and a copy of the last published report issued by CSCI is available in the entrance hall of the home. Consideration should be given to producing the Guide in alternative formats to make it accessible to those who may not be able to access standard written English. Information about service users’ views obtained during the recent quality assurance exercise should also be included in the Guide. Anita Jane`s Lodge DS0000006432.V363522.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is adequate Improvements in the level of information in support plans, means that people’s needs, can be more effectively met. Although plans state people’s aspirations they do not say how they can be supported to achieve these. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The three support plans seen demonstrated an improvement in the amount of detail relating to people’s mental ill health and how this should be managed. This included crisis plans as to how deterioration in mental health should be managed, including details of the person to be contacted for additional support. The templates used for the support plans were designed for use when supporting older people and therefore some of the information routinely assessed and included like pressure area care and falls risk assessments are not relevant to the vast majority of the people living at Anita Jane’s Lodge. This means that staff are routinely assessing for needs and completing reports unnecessarily. Discussion with two of the people whose support was focussed on and with staff, indicated that information within the plans was accurate in relation to people’s physical and mental health needs. Anita Jane`s Lodge DS0000006432.V363522.R01.S.doc Version 5.2 Page 13 Support plans did contain information about people’s aspirations, including their desire for greater independence, but did not contain any information as to how they would be supported to achieve their aspirations. Efforts are being made to give service users opportunities to undertake certain domestic tasks such as laundry and room cleaning but how this helps people achieve their goals should be outlined more clearly. Discussion with one person indicated that they were unclear as to how they would be supported to achieve their aspiration to live more independently. This suggests that people need to be more actively involved in the planning and implementation of the support they receive. Some risk assessments clearly identified the risk to the individual and the action to be taken by staff and others – this is a clear improvement on the quality of risk assessment seen at previous inspections. Some risk assessments did not clearly define the risk and therefore the information about how to respond was also unclear. One person was identified as being ‘vulnerable’ and the response to this was that staff should ‘monitor’ them to ensure that they were ‘not taken advantage of’. How this monitoring should take place and what would constitute the person being taken advantage of was not specified. This poor assessment and lack of information could lead to the person’s needs not being met and them being placed at risk. Up to date information about advocacy services has been placed on the notice board but as people were not asked specifically about this it is not known whether it has been actively promoted. New care plan templates based on person centred planning have been acquired and staff are to receive training in this approach during the summer. This should help in the implementation of a more person-centred approach to care and support. Anita Jane`s Lodge DS0000006432.V363522.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is adequate Some provision is made for people to develop skills in daily living but this is not always enabled in a way that allows them to meet their aspirations. A good variety of food is served meaning that people have access to a wellbalanced diet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Records show that a good range of food is served, which takes account of people’s likes and cultural needs. The main meal is served in the early evening to accommodate those that attend day services or other activities during the day. On the day of the inspection there was a choice of homemade fish pie with vegetables or chicken curry and rice with salad. People said that the food was good and that they had no complaints in this area. A record of each person’s diet is kept as part of their daily notes and support staff explained how they monitor certain people’s food and fluid intake. Opportunities for people to be involved in cooking and shopping are still limited although this has been identified as a need in some people’s support plans. Anita Jane`s Lodge DS0000006432.V363522.R01.S.doc Version 5.2 Page 15 Policy within the home has changed in response to requirements and recommendations made at previous inspections and some people are now encouraged to undertake domestic tasks such as cleaning their rooms and doing their laundry. People expressed a mixed response to this using words such as strict when describing staff and saying that they were told what to do. One person said that they enjoyed doing their own laundry. The registered manager must monitor staff’s approach to people who live in the home so that encouraging people to do things for themselves is not translated as staff telling people what to do. Three people spoke to the inspector about what they do during the day and evening. This included visiting local shops, going to the hairdresser, going to local cafes and for two people occasionally attending a special day service for people with needs associated with mental ill health. The third person said that they did not like these centres so did not attend and preferred to go to the library or read at home. One person also said that they enjoyed going to the park and going into town. People also spoke about trips that had been arranged to a local restaurant and to Skegness. Details of some of these trips were posted on the notice board in the dining room. One person described their regular visits to see a friend. Other people’s families visit them at Anita Jane’s Lodge and the registered manager said that they were looking to convert the manager’s office into a visitor’s room so that people could see their families and friends in private without having to use their bedrooms. Anita Jane`s Lodge DS0000006432.V363522.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 EVIDENCE: Quality in this outcome area is adequate People’s health, personal care and medication needs are generally well met but improvements in documentation would ensure consistency of approach. This judgement has been made using available evidence including a visit to this service. The three people’s support plans seen described how they preferred their personal care needs met, for one person this included information that they did not like staff in the bathroom with them. Discussion with this person indicated that their wishes were observed and that they were satisfied with the level and kind of support available. People who live in the home have a variety of physical health care needs in addition to those associated with their mental health. Generally these conditions and the kind of staff support required are identified in support plans. One person confirmed that they were supported in monitoring their diabetes and a skin condition and that staff supported them when they had to attend hospital or clinic appointments. A staff member explained how another person’s long-term health need was monitored and the response that staff made if there was a problem. The monitoring and response appeared well executed (records were kept on a daily basis) but the system of monitoring and response required was not outlined in the person’s support plan. This Anita Jane`s Lodge DS0000006432.V363522.R01.S.doc Version 5.2 Page 17 should be recorded to ensure consistency of approach from all staff members in meeting this person’s physical health needs. Two of the three people whose care was focussed on for the inspection are being supported in administering some their own medication and appropriate risk assessments are in place. One person had been assessed as being unable to administer their own medication but no reason had been given for this. This illustrates the inconsistency in the quality of risk assessments in the home. The inspector was informed that as the pharmacist had failed to deliver the Medication Administration Sheets no record had been made of the medication administered on that day or the previous day. The inspector told the manager that medication supplies must be checked and those staff that had administered medication contacted and a record made of the medication administered. This process was started during the inspection and the manager sent a letter to the Commission to confirm that it had been completed. The registered manager must ensure that provision is made for medication to be recorded if this situation arises again. There was also a quantity of medication waiting to be returned to the pharmacist, the majority of this being ‘as required’ medication not administered. No clear information is documented in relation to under what circumstances ‘as required’ medication should be given. This information should be placed on people’s support plans together with who has the authority to administer the medication and the details of the prescribing medical practitioner. Medication no longer needed should be returned promptly to the pharmacist. Anita Jane`s Lodge DS0000006432.V363522.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is adequate Peoples’ complaints are acted upon but the management of risk still needs improving to ensure that they are consistently protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints procedure (in a standard written format) is displayed throughout the home and in the Service Users Guide. A complaints book and complaints boxes are easily accessible; the book details the response taken to resolve individual complaints. People said that if they were not happy with anything they would speak to the manager. Information about advocacy services has been updated but as people were not asked directly about this it is not clear if they are aware of the new information. A staff member on duty was able to demonstrate knowledge of whistle blowing procedures and who they should report any concerns to. A letter from the local authority confirmed that staff would shortly receive training in safeguarding vulnerable adults. Although there has been improvement in the area of risk assessment this still needs to be undertaken consistently to ensure that each person’s needs are met appropriately and that they are not placed at risk because staff are unsure as to how to respond to an identified risk. Appropriate Criminal Records Bureau checks were obtained in response to the requirement made at the last inspection. A recently appointed member of staff had all appropriate recruitment checks before they began work in the home. Anita Jane`s Lodge DS0000006432.V363522.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is adequate The environment of Anita Jane’s Lodge provides accommodation that meets people’s needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Some communal areas have been redecorated and a questionnaire had been used to ask for people’s suggestions for the colour scheme for the lounge. Given the disparate suggestions given it isn’t clear how the eventual scheme was decided upon. The registered manager said that she was waiting for new furniture for this room to be delivered; it contained only one settee and one chair. Pictures have been hung to decorate the corridors, giving a more ‘homely’ and less institutional feel to the home. This could be built upon for example by ensuring that all lights had proper fittings and shades rather than bare bulbs. One person showed the inspector their recently redecorated room. They said that they had chosen the colour scheme and were very pleased with the overall result. Their room also contained a large fridge and a kettle so that they could make drinks if they wished, without having to access the main kitchen. Anita Jane`s Lodge DS0000006432.V363522.R01.S.doc Version 5.2 Page 20 The home was clean and tidy throughout and all staff have received infection control training and were observed to follow good hygiene practices. The rear garden has been cleared and the manager has employed a gardener who she hopes will work alongside one of the people living in the home who has expressed an interest in growing vegetables. The garden is now an attractive place for people to use. Anita Jane`s Lodge DS0000006432.V363522.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, 36 Quality in this outcome area is adequate Training has improved staff’s understanding of people’s needs but must be consolidated by good supervision to ensure that staff always support people appropriately. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the previous key inspection staff have undertaken training focussing on the conditions associated with mental ill health. At the random inspection on 17/01/08 the impact of this on their work was discussed with two staff members and with a further staff member during this inspection. Staff felt that it had enabled them to do their job more effectively and understand the people they were supporting better and one was able to give examples of this. The manager should ensure that time is allocated for staff supervision and discussion, to ensure that knowledge gained in training is incorporated into practice so that people are always appropriately supported. The registered manager said that she was trying to arrange training around the implications of the Mental Capacity Act and had spoken to one of the owners of the home (a Consultant Psychiatrist) about delivering this. Leicester City Council’s training support unit have been working with the registered manager and have designed an action plan for staff training. All senior staff are undertaking National Vocational Qualifications in supporting Anita Jane`s Lodge DS0000006432.V363522.R01.S.doc Version 5.2 Page 22 people at level 3 and two senior staff are to attend management training courses. The Unit are also working with the registered manager to ensure that the induction package being used in the home is appropriate for the people living there. Training has also been arranged for staff in safeguarding vulnerable adults. The registered manager said that people were being encouraged “to do more for themselves” to allow staff to focus more on working with them rather than doing basic domestic work. This represents a huge cultural change in the home and comments from people indicate that staff’s interpretation of encouragement may need some modification. One person described staff as “all right but strict” another said “They tell you what to do” while a third described the home as “disciplined”. Little interaction was observed between staff and service users during the inspection, which was not based on a particular task – such as asking someone what they would like for tea or administering medication. This suggests that more work may be needed in embedding the change of culture within the staff team. Three staff members’ recruitment files were examined – these contained two references, a Criminal Records Bureau check and evidence that their names had been checked against the vulnerable adults register. The records for a gardener recently employed to work at the home, showed that all recruitment had been carried out. Anita Jane`s Lodge DS0000006432.V363522.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is adequate People’s opinions are sought but work is needed to ensure these actively inform the running of the home. Regular monitoring by the responsible individual would ensure recent improvements in management are maintained and improved. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the start of the inspection the registered manager was examining surveys she had sent to people living in the home, staff, relatives and outside professionals asking for their opinions on the quality of the service. The findings from this exercise should be compiled into a report, which indicates how they will be used to inform the operation of the home; a copy of this report should be sent to CSCI when it is completed. Information from this exercise should also be used to help complete the Annual Quality Assurance Audit (AQAA) issued by CSCI and completed by the registered manager prior to the inspection. Some of the information returned to CSCI in this year’s Anita Jane`s Lodge DS0000006432.V363522.R01.S.doc Version 5.2 Page 24 AQAA was very brief and did not give CSCI a full picture of what was taking place within the home. The registered manager has completed training alongside her staff in the conditions associated with mental ill health and is also undertaking her Registered Managers Award. This suggests that she has recognised the need to maintain and update her skills. A requirement was made at the previous key inspection that the responsible individual (or their representative) visit the home at least once per month and compile a report based on their visits. This requirement is clearly stated in the Care Home Regulations. The responsible individual’s last visit was 19th February and a report of this visit was available. The registered manager said that the responsible individual was due to visit on 2nd May. Given that at the last two key inspections the home was assessed by CSCI as offering poor outcomes for people who live there, we would have expected to see at least the minimum required visits being made. This requirement is therefore reissued. All staff have received training in health and safety, first aid and fire safety and discussion with those on duty and observation of their practice indicated that there was good practice in these areas. Fire, electrical and gas systems are regularly tested and serviced to ensure that equipment is safe and functional. Anita Jane`s Lodge DS0000006432.V363522.R01.S.doc Version 5.2 Page 25 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 Standard No Score 1 2 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 2 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 X 2 X X 3 X Anita Jane`s Lodge DS0000006432.V363522.R01.S.doc Version 5.2 Page 26 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 YA6 Regulation 15 (1) Requirement The Registered Person must ensure that the support plans of all people who live in the home fully reflect and detail the support they require to have their needs met and to achieve their aspirations. The Registered Person must ensure that risks to the health, safety and welfare of people who live in the home are clearly identified together with the response to be taken to the identified risk. The Registered Person must ensure that a record is made of all medication administered, at the time of administration. A report based on the feedback from stakeholders as part of the quality assurance process should be compiled demonstrating how the information will inform the future operation of the service A copy of this report should be forwarded to the Commission for Social Care Inspection. The responsible individual (or his representative) should visit the DS0000006432.V363522.R01.S.doc Timescale for action 30/06/08 2. YA9 13 (4) 30/06/08 3. YA20 13 (2) 29/04/08 4. YA39 24 (2) 31/07/08 5. YA39 26 31/05/08 Anita Jane`s Lodge Version 5.2 Page 27 care home unannounced, at least once per month. During this visit people who live in the home, their representatives and staff should be interviewed, the premises inspected and the record of events and complaints viewed. A written report on the conduct of the care home should be prepared from the information gathered. Previous timescale of 15/02/08 not met. 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 YA2 Good Practice Recommendations The Service User Guide should be made available in different formats so that it is fully accessible to those people for whom standard written English may be difficult to understand. It is recommended that support plans be developed consistent with Person Centred Planning guidance and recommendations The registered manager and staff members should undertake training in risk assessment and management. Information as to under what circumstances people should be given ‘as required’ medication should be placed on their support plan together with who has the authority to administer the medication and the details of the prescribing medical practitioner. Medication no longer needed should be returned promptly to the pharmacist. The registered manager must monitor staff’s approach to people who live in the home so that encouraging people to do things for themselves is not translated as staff telling people what to do. The manager should ensure that time is allocated for staff supervision and discussion to ensure that knowledge gained in training is incorporated into practice so that DS0000006432.V363522.R01.S.doc Version 5.2 Page 28 2. 3. 4. YA6 YA9 YA20 5. 6. YA20 YA32 7. YA36 Anita Jane`s Lodge people are always supported appropriately. Anita Jane`s Lodge DS0000006432.V363522.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Anita Jane`s Lodge DS0000006432.V363522.R01.S.doc Version 5.2 Page 30 - 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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