This inspection was carried out on 6th September 2005.
CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 but made no statutory requirements on the home.
CARE HOME ADULTS 18-65
Charnwood Lodge Woodhouse Lane Nanpanton Loughborough, Leicestershire LE11 3TG Lead Inspector
Steve Hunnybun Unannounced Tuesday, 6 Septemeber 200 at 1:30pm
th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Charnwood Lodge C51 C01 S1794 Charnwood Lodge V248099 060905 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Charnwood Lodge Address Woodhouse Lane Loughbrough Leicestershire LE11 3TG 01509 890184 01509 891446 charnwood.lodge@craegmoor.co.uk Lansdowne Road Ltd Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Miss Tracey Nuttall Care Home 18 Category(ies) of LD Learning disability (18) registration, with number of places MD Mental Disorder (18) Charnwood Lodge C51 C01 S1794 Charnwood Lodge V248099 060905 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: No person falling within category MD may be admitted to the home unless that person also falls within category LD – i.e. dual disability. Date of last inspection 26th April 2005 Brief Description of the Service: Charnwood lodge is registered for eighteen service users with learning disabilities and associated challenging behaviour. The registration includes those with mental health problems in addition to their learning disability. The property is a large building set in extensive well-maintained grounds. A programme of renovation and decoration has been carried out and has greatly improved both shared and private living accommodation for residents. The home is divided into two units, Elm and Oak each with its own manager and staff team. The home has a shared activity room that is used for day care. Charnwood Lodge C51 C01 S1794 Charnwood Lodge V248099 060905 stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the second statutory unannounced inspection this year and took place over four hours. Four residents files were tracked and the inspector spoke with a number of residents. Comments from residents were generally positive. A group had been out for a long walk on the day of the inspection, which they all appeared to have enjoyed. Residents were very complementary about the staff and registered manager. They all stated that they like their rooms and the food was described as good although two residents said that they would like more healthy choices. What the service does well: What has improved since the last inspection?
None of the requirements or recommendations made at the last inspection has been fully met. Commendable progress has been made towards meeting them, however and the registered manager was able to show the inspector work in progress regarding contracts, the residents’ guide and the upgrade to parts of the building. Charnwood Lodge C51 C01 S1794 Charnwood Lodge V248099 060905 stage 4.doc Version 1.40 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Charnwood Lodge C51 C01 S1794 Charnwood Lodge V248099 060905 stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Charnwood Lodge C51 C01 S1794 Charnwood Lodge V248099 060905 stage 4.doc Version 1.40 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,5 Although significant work has happened to produce an accessible residents’ guide and contracts these documents are not yet finished. EVIDENCE: The home as yet does not have a residents’ guide that is in an accessible format. The inspector discussed this with the registered manager and this document is very much in progress. The registered manager is keen to link this with contracts for residents that clearly set out the rights and responsibilities of both the home and residents. Charnwood Lodge C51 C01 S1794 Charnwood Lodge V248099 060905 stage 4.doc Version 1.40 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 9 Residents are supported to take risks that can enhance their independence. EVIDENCE: Residents all have very useful risk assessments that enable them to make informed choices about activities. These assessments had all been regularly reviewed. Charnwood Lodge C51 C01 S1794 Charnwood Lodge V248099 060905 stage 4.doc Version 1.40 Page 10 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13,14,15,17 Residents are enabled to be part of the local community. Appropriate leisure activities are offered to residents who are also enabled to maintain contact with friends and families. Residents enjoy their food but would prefer more healthy options. EVIDENCE: Residents are enabled to access local facilities where appropriate. The home is in a rural location so this relies on the availability of transport and relevant risk assessments. A group of residents went out for a ten-mile walk on the day of the inspection. Several residents described a recent sports day event that had been held at the home, this appeared to have been enjoyable; one resident showed the inspector his medal. Residents are enabled to maintain contact with families and friends; several files contained records of contact visits. Residents described the food as good, although two residents stated that they would prefer more low fat options. This was discussed with the registered manager who stated that she is working closely with the kitchen staff to produce more healthy options. Charnwood Lodge C51 C01 S1794 Charnwood Lodge V248099 060905 stage 4.doc Version 1.40 Page 11 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 20 Due to the discrepancies in recording and storage of medication and the cleanliness of the preparation areas, it is possible that residents are at risk from medication errors, omissions or contamination. EVIDENCE: There were several missing signatures on medication sheets. Sheets for recording as required (PRN) medication have not been completed with the full indication for each medication. A tube of prescription only eye ointment was found without a pharmacy label. Staff stated that the label was on the box but clearly the tube needs to be labelled as well. It was stated that two residents were using the same ointment at the same time. This could have resulted in cross-infection with the tubes not being labelled. The medication cupboards were tidier than last time but the kitchenettes in which they are situated were still dirty with spilt drinks and sticky floors. Charnwood Lodge C51 C01 S1794 Charnwood Lodge V248099 060905 stage 4.doc Version 1.40 Page 12 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: Neither of the standards in this section was inspected on this occasion. Both were looked at during the last inspection and were met. Charnwood Lodge C51 C01 S1794 Charnwood Lodge V248099 060905 stage 4.doc Version 1.40 Page 13 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 25,30 Residents have bedrooms that support their needs and enable them to enjoy privacy. The kitchenettes need to be kept clean to prevent contamination of medication. EVIDENCE: One resident showed the inspector his bedroom. The room was large and contained a number of the residents’ personal belongings and pictures. The resident has recently moved into the room and it is currently painted in a neutral colour. The resident stated that he is going shopping to buy wallpaper to further personalise his room. A resident spoke with the inspector at the last inspection and highlighted a number of concerns she had with her room: A windowpane was cracked; contractors have been to look at the glass but were unable to gain access to the room, the resident stated that she no longer wants a bedside lamp and the light in the corridor outside the room is now working. The resident informed the inspector that the hot water tap still runs cold. This was discussed with the registered manager who stated that the home has a contract with a firm of local plumbers who are currently in the process of carrying out diagnosis and remedial work to alleviate this problem. The inspector did not look at this residents’ room as she was out for most of the inspection and has stated that she does not want people in her room when
Charnwood Lodge C51 C01 S1794 Charnwood Lodge V248099 060905 stage 4.doc Version 1.40 Page 14 she is out. Other residents who spoke with the inspector stated that they are happy with their rooms. Charnwood Lodge C51 C01 S1794 Charnwood Lodge V248099 060905 stage 4.doc Version 1.40 Page 15 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: None of the standards in this section were inspected on this occasion. They were looked at last time and were met. Charnwood Lodge C51 C01 S1794 Charnwood Lodge V248099 060905 stage 4.doc Version 1.40 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42 Whist the home is clearly proactive in areas such as fire safety the current access to the laundry presents a risk to staff and residents. EVIDENCE: The home has a comprehensive fire risk assessment. All recording relating to fire was found to be up to date and accurate. The building has recently been designated a no smoking area for residents and staff. This had been discussed with all residents and staff and has been agreed. The laundry room is housed in a part of the building that can be accessed either by going through the kitchen, or by going outside the building down some stone steps. This is clearly unacceptable; soiled linen cannot be taken through the kitchen so the outside option is used. This poses a risk that someone could fall. Charnwood Lodge C51 C01 S1794 Charnwood Lodge V248099 060905 stage 4.doc Version 1.40 Page 17 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 x x x 2 Standard No 22 23
ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score x x x 3 x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score x 3 x x x x 1 Standard No 11 12 13 14 15 16 17 x x 3 3 3 x 3 Standard No 31 32 33 34 35 36 Score x x x x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Charnwood Lodge Score x x 1 x Standard No 37 38 39 40 41 42 43 Score x x x x x 1 x C51 C01 S1794 Charnwood Lodge V248099 060905 stage 4.doc Version 1.40 Page 18 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 20 Regulation 13(2) Requirement The home is required to develop a system to ensure that all medication sheets are correctly signed for administered medication. The home is required to ensure that all information regarding the administration of PRN medication is recorded in residents care plans and on PRN procedures. This requirement is outstanding from the last inspection. It is required that all medication has an appropriate pharmacy label on it before being accepted into the home It is required that areas used for the preparation of medication are kept clean and tidy. This requirement is partly met from the last inspection. The provider is required to carry out a health and safety review of laundry provision at the home and to carry out any necessary building work. An action plan to be developed and copied to the inspector. Timescale for action 31st October 2005 31st October 2005 2. 20 13(2) 3. 20 13(3) 30th September 2005 31st October 2005 31st October 2005 4. 20 13(3) 5. 42 23 Charnwood Lodge C51 C01 S1794 Charnwood Lodge V248099 060905 stage 4.doc Version 1.40 Page 19 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. 2. 3. 4. Refer to Standard 1 5 17 25 Good Practice Recommendations It is recommended that the residents guide is produced in a form that is accessible to people with learning disabilities. It is recommended that all residents have contracts in their files. It is recommended that a healthy option be available at all meals. It is recommended that work is carried out to rectify the problems with the window glass and the hot water in the bedroom mentioned in the report. Charnwood Lodge C51 C01 S1794 Charnwood Lodge V248099 060905 stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection The Pavilions 5 Smith Way Grove Park, Enderby Leicester, LE19 1SX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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