CARE HOME ADULTS 18-65
Christmas Lodge 196 Mount Vale York YO24 1DL Lead Inspector
Mrs Anne-Marie Foster Unannounced Inspection 15th March 2006 10:00 Christmas Lodge DS0000015802.V279894.R01.S.doc Version 5.1 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 Christmas Lodge DS0000015802.V279894.R01.S.doc Version 5.1 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. Christmas Lodge DS0000015802.V279894.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Christmas Lodge Address 196 Mount Vale York YO24 1DL 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) 01904 647442 01904 675581 Mr Dale Andrew Graver Mrs Penelope Anne Graver, Mrs Lynne Dexter Mrs Carol Georgina Irvine Care Home 15 Category(ies) of Learning disability (15), Learning disability over registration, with number 65 years of age (15), Mental disorder, excluding of places learning disability or dementia (15), Mental Disorder, excluding learning disability or dementia - over 65 years of age (15) Christmas Lodge DS0000015802.V279894.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Registration is for 15 persons with a mental health disorder and/or a learning disability some of whom may be over 65. 19th October 2005 Date of last inspection Brief Description of the Service: Christmas Lodge is a care home providing personal care and accommodation for up to 15 service users with mental health needs and/or learning disabilities. The home is located close to the centre of York and is within walking distance of the city the amenities and leisure facilities. The accommodation provided is both single and double bedrooms, self-contained units and a variety of spacious communal rooms. Christmas Lodge is privately owned by Mr and Mrs Graver and Mrs Dexter and was registered in 1998. There is a small garden at the front and a pleasant courtyard with parking at the back of the house. Christmas Lodge DS0000015802.V279894.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on 15TH March 2006.The inspection took five hours, including three hours of preparation time. The senior carer was available to assist with a tour of the building, including service users rooms. Time was spent observing the activity in the home and listening to the interactions between staff and the service users. 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. Christmas Lodge DS0000015802.V279894.R01.S.doc Version 5.1 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 Christmas Lodge DS0000015802.V279894.R01.S.doc Version 5.1 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): None of these standards were inspected on this occasion. EVIDENCE: Christmas Lodge DS0000015802.V279894.R01.S.doc Version 5.1 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): None of these standards were inspected on this occasion. EVIDENCE: Christmas Lodge DS0000015802.V279894.R01.S.doc Version 5.1 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): 15 and 17 Service users are enabled to enjoy a lifestyle with a healthy and varied diet, and they are supported in order to have appropriate relationships. EVIDENCE: Service users are enabled to take responsibility for most aspects of their lives and are involved in decision making about the daily activity in the home including menu planning, with emphasis on a healthy diet. Visitors are made welcome in the home and family and friends can come and go as the service user wishes. The staff support the service users in having appropriate personal relationships. Christmas Lodge DS0000015802.V279894.R01.S.doc Version 5.1 Page 10 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): None of these standards were inspected on this occasion. EVIDENCE: Christmas Lodge DS0000015802.V279894.R01.S.doc Version 5.1 Page 11 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): None of these standards were inspected on this occasion. EVIDENCE: Christmas Lodge DS0000015802.V279894.R01.S.doc Version 5.1 Page 12 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): None of these standards were inspected on this occasion. EVIDENCE: Christmas Lodge DS0000015802.V279894.R01.S.doc Version 5.1 Page 13 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 A team of appropriately trained staff supports the service users, allowing their individual and joint needs to be met. EVIDENCE: The staff training programme includes induction training for all new employees, including fire safety, health and safety, food handling, first aid, control of infection. Other staff training includes NVQ, mental health foundation training, medication and abuse awareness training. There are good numbers of staff on the duty rota. Christmas Lodge DS0000015802.V279894.R01.S.doc Version 5.1 Page 14 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): 39 Service users benefit from a well managed home where their needs are put first. EVIDENCE: The home gives out self monitoring questionnaires, and holds regular residents meetings, both of which enable the service users and their families or contacts to express their views; which the home uses as a quality assurance system. Christmas Lodge DS0000015802.V279894.R01.S.doc Version 5.1 Page 15 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 X 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 X 23 X ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 x 32 x 33 x 34 X 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X x LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X X X 3 X X X X Christmas Lodge DS0000015802.V279894.R01.S.doc Version 5.1 Page 16 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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 A 19 Good Practice Recommendations The registered manager should promote the health of the service users by reviewing the staff smoking policy. Christmas Lodge DS0000015802.V279894.R01.S.doc Version 5.1 Page 17 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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