Inspection on 17/11/05 for Bishops Lodge

This inspection was carried out on 17th November 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 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Bishops Lodge 10/11/08

Bishops Lodge 10/11/06

Bishops Lodge 25/04/05

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Bishops Lodge 19 Fearon Road Hastings East Sussex TN34 2DL Lead Inspector Rebecca Shewan Unannounced Inspection 17th November 2005 09:30 Bishops Lodge DS0000061586.V265650.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 Bishops Lodge DS0000061586.V265650.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. Bishops Lodge DS0000061586.V265650.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Bishops Lodge Address 19 Fearon Road Hastings East Sussex TN34 2DL 01424 421684 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) gaylenewdirections@tiscali.co.uk New Directions (Hastings) Ltd Mrs Amanda Elizabeth Jane Gates Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Bishops Lodge DS0000061586.V265650.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The maximum number of service users to be accommodated is five (5) Service users must be aged between eighteen (18) and sixty-five (65) years on admission Service users with a learning disability only to be accommodated Service users with Praeder Willi Syndrome may be accommodated Date of last inspection 25th April 2005 Brief Description of the Service: The home is situated in a detached Victorian house on the outskirts of Hastings. It is situated close to local shops, a local park and bus routes. Ore railway station is about a mile away. It was registered on the 29th October 2004 to provide care to five younger adults with a learning disability. The home is registered to provide accommodation for five younger adults with a learning disability predominantly those with Prader-Willi syndrome. At the rear of the home there is a garden, which slopes up away from the house, and decking has provided areas to sit. There is a building at the rear, which is used to provide an in-house day care centre. Accommodation is on two floors. There is adequate communal space and each service user has a single bedroom. Four of the bedrooms have en-suite facilities and the fifth has the use of a bathroom nearby. There are parking spaces to the front of the home. Bishops Lodge DS0000061586.V265650.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second unannounced inspection to take place in the CSCI inspection year of 2005/2006. To gain a complete overview of the standards assessed it will be necessary to read both inspection reports for this inspection year. This inspection took place during the morning and early afternoon of the seventeenth November 2005. Before the inspection papers held by the Commission for Social Care Inspection were read. The inspection of the home took five and a half hours. A tour of the whole home was undertaken and the Registered Manager, the Development and Liaison Officer, four service users and a visitor to the home were spoken with. There were four service users (known as residents) residing at the home at the time of the inspection. What the service does well: What has improved since the last inspection? What they could do better: The homes’ written and pictoral Complaints Procedure will require updating to include that the CSCI can be contacted at any time on the event of a complaint, once completed the Service Users Guide and Statement of Purpose will require updating to include the amended Complaints procedure. Urgent action should be taken by the home to ensure; that all handwritten entries onto MAR sheets are signed, dated and an explanation given (detailing the reason of the handwritten data) by the person completing the entry and that static soap dispensers are utilised in order to reduce the element of risk to residents. Bishops Lodge DS0000061586.V265650.R01.S.doc Version 5.0 Page 6 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. Bishops Lodge DS0000061586.V265650.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 Bishops Lodge DS0000061586.V265650.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 & 3 There is a need for the Home to update its Service User Guide and Statement of Purpose to ensure that all residents (new and existing) are aware of the homes revised Complaints Procedure. The home has good processes for assessing prospective new service users. EVIDENCE: The Service User Guide and Statement of Purpose are provided to all new and existing service users. However both documents require some minor updating e.g. a copy of the revised complaints procedure will need to be attached. Records inspected showed that Pre admission assessments are carried out on all new and potential service users. The home also obtains a copy of a care management assessment from a placing authority where this exists. The Manager said that potential residents would be declined if necessary, if it were deemed that the home could not meet their needs. Bishops Lodge DS0000061586.V265650.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): 6,7 & 9 The care plans are detailed and suitable for meeting service users needs. Residents are encouraged to have control over their lives and to exercise choice and be independent in their decision-making. The home has good processes in place for recording and handling of monies that they hold for residents. Risk assessments are satisfactory and encourage service user independence. EVIDENCE: Individual residents care plans were sampled and it was noted that these are person centred. The Manager said that these care plans are devised from the information found in the pre admission assessment and from verbal information from the service user. The promotion of independence is key to the residents living a full and independent life. The home is run to ensure that the resident’s are encouraged to maintain their independence in making choices and decisions relating to their daily living and their life outside of the home. Any information relating to service user choice or decision-making is recorded in the service Bishops Lodge DS0000061586.V265650.R01.S.doc Version 5.0 Page 10 user’s care plan. Residents are encouraged to manage their own finances, where able and assistance is given to those who require it. Records and receipts viewed for residents’ accounts held with the home where thorough and monetary amounts were the same as the accounts maintained. Care plans that were viewed also included details of areas of risk relating to all aspects of the residents daily living. An action plan, which details how to assist the resident in reducing or eliminating the risk/crisis factors, is formulated and reviewed six monthly or on an as required basis. Bishops Lodge DS0000061586.V265650.R01.S.doc Version 5.0 Page 11 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 & 17 The home assists residents with maintaining independence in their daily living and daily routines. Service users are treated with respect and there is good rapport between staff of the home and residents. The home arranges meals that are suitable in quantity and variation and provide residents with the means to maintain a healthy diet, in accordance with the needs of their syndrome. EVIDENCE: Residents are actively encouraged to go shopping once a week and to attend events held in the local community such as going to the local pub, swimming, horse riding and the gym. Residents are assisted to maintain attendance to the homes in house day centre from 9am to 5pm, Monday to Friday. Residents also attend Bishop Corner (a partner home of New Directions) for numeracy and literacy skills, which is conducted by a tutor from Hastings College. All residents attend college courses and one resident has a job. Bishops Lodge DS0000061586.V265650.R01.S.doc Version 5.0 Page 12 The home has well-established links to local community events and activities. Residents are actively encouraged to maintain family contact and that visitors could attend the home at any time and in accordance with the service users wishes. Residents can entertain their guests in any of the homes communal areas or privately in their own bedrooms. The inspector joined the home for the lunchtime meal and it was observed that mealtimes are taken as a ‘family’ with both staff and residents having meals together at the main dining table. Residents said that they enjoy the food served in the home and that staff were good at helping them to achieve weight lose. Resident’s may have guests to stay for a meal at any time. The Manager said that medical or therapeutic diets are provided as needed. The meal served during the inspection was ample in quantity and attractively presented. From the care plans sampled it was evident that nutritional needs and dietary assessments are carried out on residents. Residents are weighed on a weekly basis and residents are assisted in maintaining their diet in order to meet their target weight. Strategies are in place that enables residents to be independent in coping with influences that could hinder their dietary regime. The manager said that residents had in the past declined attendance to a local support group, as food was made freely available. Bishops Lodge DS0000061586.V265650.R01.S.doc Version 5.0 Page 13 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): 18 & 20 Residents are treated with respect, privacy and dignity. The home has to make some improvements in recording handwritten entries onto Medication Administration Record (MAR) sheets. The home has good processes in place to enable residents to self medicate. EVIDENCE: The Manager said that personal care is provided minimally. Personal support that is offered is given in such a way as to promote and protect service users privacy and dignity, whilst promoting their independence. Service users informed the inspector that they are treated with dignity and that their privacy is respected at all times. The home has good procedures in place for the monitoring and recording of all drugs entering and leaving the home and drugs being administered. However, some improvement is required in ensuring that handwritten entries onto MAR sheets are dated, signed and an explanation of the reason for a handwritten entry being detailed. The implications of this were discussed with the Manager at the time of the inspection. Residents who are able are assisted to self medicate and it was noted that suitable risk assessments were in place to encourage independence with medication taking. Bishops Lodge DS0000061586.V265650.R01.S.doc Version 5.0 Page 14 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): 22 & 23 The home has a complaints procedure that requires amending in order to meet the Standard and relevant regulations. The homes procedures, processes and training of staff should protect service users in the event of any allegation of abuse. EVIDENCE: The home’s Complaints Procedure is available in both a written and pictoral format. The complaints procedure currently states that the CSCI can only be contacted if the complaint has not been satisfactorily resolved by the home. Therefore, the written and pictoral complaints procedure will require amending to detail that the CSCI can be contacted at any time in the event of a complaint. Neither the CSCI nor the home has received any complaints in the last twelve months. Records viewed showed that Protection of Vulnerable Adult training is carried out by New Directions on a yearly or as required basis. The Manager said that all the residents currently have an advocate. Residents are protected from abuse, neglect and self-harm at all times. This was evident from the care plans and risk assessments viewed. The previous inspection requirement that resident’s monies are consistent with the records maintained has now been fully met. Bishops Lodge DS0000061586.V265650.R01.S.doc Version 5.0 Page 15 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): 24,25,27 & 30 The home provides a good quality of accommodation. Communal areas and bedrooms are maintained to a good standard, providing pleasant accommodation. The home has good processes in place for ensuring good infection control procedures are maintained within the home. EVIDENCE: The location and layout of the home are suitable for its stated purpose. The home is well maintained and all areas of the home, including the garden, are accessible to residents. The home has an ongoing plan of refurbishment in place. Resident’s bedrooms are pleasantly decorated. Residents said that they are actively encouraged to bring in their own possessions and personalise their bedrooms. This was evident from the resident’s bedrooms viewed at the time of the inspection. There are ample toilet and bathroom facilities for residents. Four of the five bedrooms have en-suite facilities and one resident’s bedroom has a bathroom next to their room. Bishops Lodge DS0000061586.V265650.R01.S.doc Version 5.0 Page 16 The home was clean and odour free throughout. An effective infection control procedure is in operation in the home. Bishops Lodge DS0000061586.V265650.R01.S.doc Version 5.0 Page 17 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): 35 Staff are appropriately trained to do their jobs. The home has good systems and processes in place for staff training. EVIDENCE: Individual staff training files were viewed and it was evident that staff training in induction and foundation programmes, First Aid, Fire Safety, manual handling, Health and Safety, food hygiene, Protection of Vulnerable Adults, Prader-Willi Syndrome, behaviour management, risk assessing, managing relationships and behaviour management. The staff induction-training package was viewed and this was found to be comprehensive in content. The home also has Foundation training in place which staff complete after induction training, this is to be completed by new staff within six months of being in employment. The aim of the foundation training is to prepare staff to undertake a National Vocational Qualification (NVQ) if they have not already obtained one. Although there is a good induction and foundation training package in place, New Directions are currently in the process of revising both training packages. Bishops Lodge DS0000061586.V265650.R01.S.doc Version 5.0 Page 18 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): 37,39 & 42 The home’s manager is competent and experienced to run the home and meet its stated purpose. Effective Quality Assurance procedures are in place and appropriate action is taken to address issues highlighted by responses received by the home. The home must make some improvements in ensuring resident safety at all times. EVIDENCE: The home’s manager has many years experience of working with younger adults with learning disabilities and is currently undertaking the Registered Managers Award (RMA). The Manager said that she aims to complete the RMA early next year. Therefore, the previous inspection recommendation that the manager should obtain the recommended qualifications in care and management has not yet been met in full. Bishops Lodge DS0000061586.V265650.R01.S.doc Version 5.0 Page 19 The home has a Quality Assurance Procedure in place. The Manager said that that she is currently in the process of conducting staff questionnaires and that within the next week resident and visitor questionnaires would also be distributed. The Manager confirmed that once in receipt of all responses a report of the findings would be published. Regulation 26 visits are carried out by the Registered Providers and copies of the report are sent to the CSCI. Records of monthly staff and resident meetings were viewed and there was evidence of actions taken to address any issues raised. The home’s maintenance files were viewed and it was evident that fire drills, fire alarm testing, emergency lighting testing and water checks are carried out on a weekly, monthly or annual basis. From the records viewed it was evidenced that Portable appliance testing had been completed in July of this year. During the tour of the home it was evident that non-static soap dispensers were in use a bathroom and the laundry area. The potential risk to residents and the implications of this were discussed with the Manager at the time of the inspection and an immediate requirement was made. It was pleasing to note that the Manager had taken actions to address this requirement prior to the inspection being completed. Bishops Lodge DS0000061586.V265650.R01.S.doc Version 5.0 Page 20 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 3 3 X X Standard No 22 23 Score 2 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 X 3 X X 3 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 X X X X 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Bishops Lodge Score 3 X 2 X Standard No 37 38 39 40 41 42 43 Score 3 X 3 X X 2 X DS0000061586.V265650.R01.S.doc Version 5.0 Page 21 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 Regulation Requirement Timescale for action 17/12/05 YA1 & YA22 5(e) & 7(b) 2 YA20 13(2) 3 YA42 12(1)a &13(4) abc That both the home’s written and pictoral Complaints Procedure is updated to include that the CSCI can be contacted at any time in the event of a complaint. Once amended the Service user Guide and Statement of Purpose will also require updating to include this information. That all handwritten entries onto 17/11/05 MAR sheets are signed, dated and an explanation given (for the reason of the handwritten data) by the person completing the entry. This is an immediate requirement. That static soap dispensers are 17/11/05 utilised in order to reduce the element of risk to residents. This is an immediate requirement. Bishops Lodge DS0000061586.V265650.R01.S.doc Version 5.0 Page 22 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 YA37 Good Practice Recommendations The manager should obtain the recommended qualifications in care and management. Bishops Lodge DS0000061586.V265650.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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. 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