Inspection on 11/10/06 for Cedar Lodge

This inspection was carried out on 11th October 2006.

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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cedar Lodge 03/09/07

Cedar Lodge 11/01/06

Cedar Lodge 27/09/05

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Cedar Lodge 169 Westbury Road Southend on Sea Essex SS2 4DL Lead Inspector Sarah Axam Unannounced Inspection 11th October 2006 10:15 Cedar Lodge DS0000062765.V313182.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 Cedar Lodge DS0000062765.V313182.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. Cedar Lodge DS0000062765.V313182.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cedar Lodge Address 169 Westbury Road Southend on Sea Essex SS2 4DL 01702 301652 01702 217625 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) Westelm Homes Ltd Manager post vacant Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Cedar Lodge DS0000062765.V313182.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 11th January 2006 Brief Description of the Service: Cedar Lodge is a privately owned care home providing personal care and accommodation for eight service users who have a learning disability. The home is a detached eight bed roomed chalet which is situated in a quiet residential area in the South church region of Southend. The home is located close to local bus routes and shops. All service users have their own rooms, which they can decorate and personalise as they choose. Communal areas include a spacious lounge, a dining room and large kitchen. The home was opened in 1993. Cedar Lodge DS0000062765.V313182.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced. Upon arrival the home felt homely, welcoming, clean and service users looked relaxed and happy. During the Inspection four staff and three residents were spoken with. A service user showed me around the premises on his own accord and staff were supportive of him doing so. Staff were observed to be fully engaged in appropriate activities with the service users. The inspection took place over 5.5 hours staff and some time was spent looking through necessary paperwork. What the service does well: What has improved since the last inspection? 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. Cedar Lodge DS0000062765.V313182.R01.S.doc Version 5.2 Page 6 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 Cedar Lodge DS0000062765.V313182.R01.S.doc Version 5.2 Page 7 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): 2 Quality in this area is good. This judgement has been made using available evidence including a visit to this service. Cedar Lodge demonstrated that it has procedures, which meets the needs of individuals prior to admission. EVIDENCE: Pre-admission and initial assessments are in place. There have been no new service users admitted recently. Yearly reviews of service users have gone ahead and are due to be rearranged, the first one scheduled on 16/10/06. A new statement of purpose has been written, which includes Staff training and qualifications and complaints procedure. Care plans have been based on person centred planning and were evidenced as being written and recorded from the services users needs, likes and dislikes. Care plans and risk assessments are written in a format of that individual’s communication choice. Cedar Lodge DS0000062765.V313182.R01.S.doc Version 5.2 Page 8 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 Quality in this area is adequate. This judgement has been made using available evidence including a visit to this service. The manager needs to make sure care plans include review dates and service users signatures to evidence they have been consulted as part of this process. EVIDENCE: The care plan itself has a ‘holistic’ approach and covered all areas of a person’s life which you would hope to be included such as preferences, safety, communication, spiritual, education and what individuals could or should be encouraged to do. Risk assessments were in place and it was good to see that risks corresponded with the care plan inspected. Risk assessments in general were of a good standard. Care plans and risk assessments need to include evidence that service users have signed and dated when they have been consulted with regarding these issues. Cedar Lodge DS0000062765.V313182.R01.S.doc Version 5.2 Page 9 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): 12,13,15,16 & 17 Quality in this area is excellent. This judgement has been made using available evidence including a visit to this service. The team and director/ acting manager evidenced a dedicated and consistent approach, non-judgemental attitudes and high standard of professionalism is in practice. EVIDENCE: Overall service users spoken with during the inspection evidenced that staff were very proactive in supporting them to take up appropriate and meaningful activities within the home and whilst out using the community. On the day of inspection it was evidenced that staff were accompanying individuals to use the community and carry out activities, which service user’s had requested. Paperwork evidenced that staff in general gave a high quality service and support. In the last year all day service that were previously funded by the local authority were withdrawn from the service users at Cedar Lodge. The home has took into consideration what impact the closure of day services has had on service users lives and as a result have made sure that individuals stay in touch with friendships made during this time. Staff support individuals to Cedar Lodge DS0000062765.V313182.R01.S.doc Version 5.2 Page 10 attend a weekly ‘friendship group’ so that they can stay in touch and maintain these friendships. In response to day services closing the home has actively put together a comprehensive leisure, social and educational activities plan for all individuals. Activities for service users are tailor made and meaningful to that person. One service user has paid work once a week. Every service user in the home has a busy and varied schedule including attending various evening clubs and activities through out the week. Additionally each service users has a day in the week where they receive 1-1 support from staff to take responsibility and to learn and maintain skills around the home. This includes ironing, washing general cleaning, washing up and the preparation and cooking of the evening meal. A number of service users have personal relationships within and outside of the home and staff supports this in a responsible and positive way. Relatives are encouraged to visit the home and made to feel welcome, service users spoken with informed me they have regular contact and would go home to relatives on regular weekend visits. The home makes individual’s birthdays and other ‘special’ occasions a chance for relatives, service users and staff to socialise together. Menus looked nutritious and reflected residents tastes. Once a month service users have a take away of their choice. On the day of inspection service users were asked about the food provided and were very complementary about the food provided and how staff supported them to be involved in the preparation, cooking and the buying of foods. Cedar Lodge DS0000062765.V313182.R01.S.doc Version 5.2 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this area is good. This judgement has been made using available evidence including a visit to this service. The homes policies, procedures and discussion with service users, staff, evidenced good practice is in place. EVIDENCE: Service users are given a choice of how they would like to be supported concerning personal care and this is recorded in their care plans. Promotion of independence and learning/retaining skills was evident. All service users have access to a GP and dental practice either local or of the individuals choice. Specialist services are catered for if necessary. Good paperwork was evidenced which shows strong links and good partnerships with the local PCT team. Recording of health care appointments, decisions and meeting were in place. A Monitored medication dosage system is in place for service users. Medication is stored in a lockable cabinet and the administration records were being maintained in accordance with agreed procedures. Record sheets had been correctly recorded and signed for. Cedar Lodge DS0000062765.V313182.R01.S.doc Version 5.2 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this area is good. This judgement has been made using available evidence including a visit to this service. The home has a complaints policy and the service user guide highlights the complaints procedure. The homes policy and procedures and training of staff appear to protect residents from abuse. EVIDENCE: All complaints information is up to date. No complaints have been made to the CSCI since the last inspection. POVA training is in place for most staff and there are further plans for two staff to attend this course. One staff member who was spoken with on the day of inspection and had not had pova training, had evidenced they were able and well informed of how to protect service users from abuse and who to inform. Cedar Lodge DS0000062765.V313182.R01.S.doc Version 5.2 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this area is excellent. This judgement has been made using available evidence including a visit to this service. On the whole the outside environment is pleasant, attractive and provides appropriate and practical usage for the service users of cedar lodge. The home environment provides a clean, comfortable and safe environment in which to live in. EVIDENCE: The cleanliness and hygiene of the home is to a very high standard, it was clean, odourless and immaculately clean in all personal and communal areas. Individual bedrooms were well furnished, decorated, maintained and personalised. The home environment present no health and safety issues, the overall environment is homely, comfortable and practical for the use of service users at Cedar Lodge. Cedar Lodge DS0000062765.V313182.R01.S.doc Version 5.2 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this area is adequate. This judgement has been made using available evidence including a visit to this service. The staff team are a mixture of NVQ qualified and staff presently training on the NVQ. EVIDENCE: At this present time 5 staff at Cedar Lodge are NVQ trained. Cedar Lodge has fewer than 50 of its staff NVQ trained. This is due to difficulties with NVQ providers not being able to sustain the level of support needed to enable staff to complete this course fully. The current acting manager is arranging for this to be resolved and has put more staff forward for new NVQ courses with different providers and has managed to access grants to secure this. The home’s induction pack is to a good standard, however this needs to be fully implemented. New staff receive support by shadowing more experienced staff before carrying out duties on their own. Regular training, supervision and staff meetings go ahead and staff spoken with on the day of inspection confirmed this. Staff records were also inspected and records evidenced training had been carried out and future training had been arranged. Cedar Lodge DS0000062765.V313182.R01.S.doc Version 5.2 Page 15 Paperwork for staff recruitment was looked at and overall was to an adequate standard, however a gap in recording a POVA 1st check for a new member of staff need to be pursued, clarified and recorded. The owner and management need to look at their policies around these issues. Cedar Lodge DS0000062765.V313182.R01.S.doc Version 5.2 Page 16 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 Quality in this area is good. This judgement has been made using available evidence including a visit to this service. Looking at paperwork and through discussion with individual residents and staff evidenced good teamwork and clear leadership skills from the director/acting manager in situations that are sensitive. EVIDENCE: The current acting manager Bronwyn Burrell is also a director of Westelm Homes Ltd. Her position at Cedar Lodge is only temporary until a new manager is employed – she has been in post since the beginning of September 2006. Bronwyn has a number of years experience as a registered care manger at another home and holds an advanced management in care certificate as well as a degree in teaching. The present acting manager has clearly made a positive impact on the running of the home. Staff and service users appear contented with the current situation of the home being under her leadership. The acting manager and deputy have made sure that continuity of service and quality of care has been maintained throughout this transitional period for the service users and staff of the home. Service users are benefiting from a strong Cedar Lodge DS0000062765.V313182.R01.S.doc Version 5.2 Page 17 management team and they have been successful in maintaining the level of service to a good standard. The Quality Assurance monitoring which gathers views of all interested parties is yet to come to fruition. The home has carried this out this procedure, however information needs collating, an action plan put into place and a report made of these findings. This report needs to be made available to all interested people with a copy sent to the CSCI. Health, safety and welfare of service users and staff have been made a priority. All but one-health and safety checks inspected were up to date. The acting manager needs to make sure the current gas certificate is put into place as a priority. Cedar Lodge DS0000062765.V313182.R01.S.doc Version 5.2 Page 18 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 X 2 3 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 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Cedar Lodge DS0000062765.V313182.R01.S.doc Version 5.2 Page 19 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 YA42 Regulation 42 (4) (x) Requirement The manager must ensure that the gas safety certificate is put into place immediately. Timescale for action 11/10/06 2. YA34 17(2) Schedule 4 19 (4)(a) The manager must ensure robust 11/10/06 recruitment procedures are in place. This refers to POVA 1st checks being recorded appropriately. This is a repeat requirement 28/02/06 The home must ensure that Quality-monitoring information is collated and actions plan with outcomes are completed and a copy forwarded to CSCI office. 31/12/06 3. YA39 24 (2) Cedar Lodge DS0000062765.V313182.R01.S.doc Version 5.2 Page 20 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. 3. Refer to Standard YA35 YA42 Good Practice Recommendations The homes staff induction programme should meet the standards of the Learning Disability Award Framework. The home should ensure that fire door closure fittings are maintained for the purpose as intended. Cedar Lodge DS0000062765.V313182.R01.S.doc Version 5.2 Page 21 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 Cedar Lodge DS0000062765.V313182.R01.S.doc Version 5.2 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!