Inspection on 20/07/05 for Christmas Lodge

This inspection was carried out on 20th July 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Christmas Lodge 09/10/07

Christmas Lodge 25/10/06

Christmas Lodge 15/03/06

Christmas Lodge 02/03/05

Christmas Lodge 19/10/04

Christmas Lodge 18/02/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 Christmas Lodge 196 Mount Vale York YO24 1DL Lead Inspector Mary Slattery Unannounced 20 July 2005 11:00 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. Christmas Lodge J53_J04_S15802_Christmas Lodge_V236981_200705_stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Christmas Lodge Address 196 Mount Vale York YO24 1DL 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) 01904 647442 01904 675581 dalegraver@btopenworld.com 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 J53_J04_S15802_Christmas Lodge_V236981_200705_stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 15 service users with mental disorder and/or learning disability some of whom may be over 65 years of age. Date of last inspection 2nd March 2005. 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 coutyard with parking at the back of the house. Christmas Lodge J53_J04_S15802_Christmas Lodge_V236981_200705_stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report relates to an unannounced inspection carried out on the 20th July 2005. The inspection took 4 hours plus 2 hours preparation time. A tour of the premises was carried out which included service users private accommodation. A selection of the homes records were inspected and time was spent observing the activity in the home, talking and listening to service users and the staff. The focus of the inspection was on a number of the key standards, inspecting the case records of a number of the service users to see if they corresponded with their experience of life in the home. The registered manager was available throughout the inspection and the findings were discussed with her at the close of the inspection. What the service does well: The service users told me they liked living in the home and that they had opportunities to be involved in a lot of activities both in the home and in the local community. A number of the service users had been on holidays and time was spent taking about their experiences. They have free access to the home, the communal rooms and have facilities to make drinks and snacks when they choose. The home is well maintained and was warm, clean and comfortable at the time of the inspection. The service users are fully involved in choosing the décor for their own rooms and there is sufficient space for their personal belongings. Some of the rooms are shared and there is a policy to ensure that service users are happy to share with someone with similar interests. There are good systems in place for all aspects of the service to be monitored by the registered manager and registered proprietors. All of the required records were in place and the service users care plans were in good order and informative. There were detailed risk assessments in place with guidance for both service users and staff to minimise risk. There was information about the health care needs and the arrangements for appointments and treatments. There is a robust system in place for the recruitment, selection training and supervision of all staff. A member of staff who has worked at the home for a number of months told me about the induction process, the training undertaken and the support received by the staff team. Christmas Lodge J53_J04_S15802_Christmas Lodge_V236981_200705_stage 4.doc Version 1.40 Page 6 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 J53_J04_S15802_Christmas Lodge_V236981_200705_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 Christmas Lodge J53_J04_S15802_Christmas Lodge_V236981_200705_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) 1,2,3,4 and 5. People are provided with the information they need to make a decision to move into the home. Information is gathered about people to ensure that their needs can be met in a safe way. EVIDENCE: The statement of purpose and the service user guide looked at gave clear information to both service users who are living in the home and prospective service users about Christmas Lodge, the services and facilities provided the staffing arrangements, the assessment and admission procedures. The documents are made available to prospective service users upon request and copies are given to service users currently living in the home. The assessment tool used enables staff to gather a lot of information about prospective service users. Arrangements are made for staff to meet with the prospective service users and to gather information from various sources including the service user and where appropriate the care manager. Service users are invited to visit the home and to move in on a trail basis before a decision is made about them moving in permanently. Christmas Lodge provides care to service users with mental health needs and/or learning disabilities and the staff training programme in place is focused Christmas Lodge J53_J04_S15802_Christmas Lodge_V236981_200705_stage 4.doc Version 1.40 Page 9 on enabling staff to gain the skills they need to deliver the care which the home offers to provide. All of the service users had a copy of their agreed contract with the home and placing authority on their files. Christmas Lodge J53_J04_S15802_Christmas Lodge_V236981_200705_stage 4.doc Version 1.40 Page 10 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) 6,7,8,9 and 10. Service users are enabled to live as independently as possible taking into account any risks that need to be considered. EVIDENCE: The care plans looked at gave clear information about all aspects of the service users personal and social support and health care needs. The care plans are generated from the assessments and they set out how the service users needs are to be met and by whom. There was information about the type and level of support they need and information about what they do independently. The service users are involved in planning their care, informed about any plans that are in place for the management of risk and challenging behaviour. Each service user has a key worker, this arrangement ensures that they have one to one time and support with the activities of daily living and time to discuss any problems or concerns they may have. There was up to date information about any treatments and interventions from external health care professional including input from the mental health services. Risk is assessed and service users are given guidance about how to minimise risks to enable them to maintain an independent lifestyle. Service users are free to enter and leave the home when they wish, transport and staff support is arranged where needed. Christmas Lodge J53_J04_S15802_Christmas Lodge_V236981_200705_stage 4.doc Version 1.40 Page 11 There are systems in place for staff to keep regular records about the service users and for the review of their care. The home has a confidentiality policy to which all staff sign up to and the service users are aware that information about them is kept secure. Christmas Lodge J53_J04_S15802_Christmas Lodge_V236981_200705_stage 4.doc Version 1.40 Page 12 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) 11,12,13, and16. Service users have a varied lifestyle and have opportunities to take part in social and occupational activities in the local community. EVIDENCE: The service users care plans detail their individual preference of activities and the contact they have with their families and friends. Service users made positive comments about life in the home. They are enabled to take responsibility for most aspects of their lives and they are involved in making decisions about the daily activity in the home. They are involved in taking care of their own rooms, working locally, attending day services, engaging in their own interests and hobbies and going on holidays. Time was spent looking at holiday photographs and chatting about the holiday one of the service users had been on. Service users have access to drinks and snacks and in planning the menu. Christmas Lodge J53_J04_S15802_Christmas Lodge_V236981_200705_stage 4.doc Version 1.40 Page 13 The staff support the service users in keeping contact with their family and friends. Some of the service users visit their family on a regular basis. Christmas Lodge J53_J04_S15802_Christmas Lodge_V236981_200705_stage 4.doc Version 1.40 Page 14 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) 18,19and 20. There are good systems in place to ensure that the service users person and health care needs are met. EVIDENCE: The service users are registered with a General Practitioner and have input from a range of external health care professional when needed. Each person living in the home needs differing levels of support with their personal and health care, keeping health care appointments and managing their own medication. The details of the levels of support and the outcomes of any treatments and interventions are recorded. A number of the service users manage their own medication and are provided with lockable facilities for safe storage and support and guidance from staff. A number of the staff have completed the appropriate medication training. Christmas Lodge J53_J04_S15802_Christmas Lodge_V236981_200705_stage 4.doc Version 1.40 Page 15 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) 22 and 23. The home has a relevant complaints procedure and the staff’s awareness of abuse ensures that service users are protected. EVIDENCE: The home has a clear complaints procedure and the details of how to make a complaint are displayed in the house and are to be found in the service user guide. The service users spoken with said they would complain to the manager if they were unhappy with any aspect of their care or the services. Service users meetings are arranged but service users do not always take the opportunity to attend. Staff have attended abuse awareness training and there is an adult protection and whistle blowing policy available for staff to refer to. It is recommended that all staff become familiar with the procedure for reporting any allegations or suspicions of abuse in line with the local authorities policy. Christmas Lodge J53_J04_S15802_Christmas Lodge_V236981_200705_stage 4.doc Version 1.40 Page 16 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) 24,26,28,29 and 30. The standard of the environment is good and provides service users with a safe, interesting, comfortable and clean place to live in. EVIDENCE: The home is decorated and furnished to a high standard and there are systems in place for redecoration, refurbishment and maintenance. There are two communal rooms one of which is a smoking room. The service users have free access to the home and the communal areas. There is a pleasant patio area with seating at the back of the house for people to use. Service users bedrooms are fitted with locks and they have their own keys. The service users are involved in choosing the décor for their rooms and the rooms looked at were filled with their own belongings. Some of the rooms are shared and there is a policy on sharing to ensure service users are happy to share and that they have compatible interests. There are no service users currently accommodated who require any specialist equipment to assist them with their mobility. There is an assisted bath should this be needed at any time. There premises were clean and free from offensive odours and there are systems in place for infection control and protective clothing is provided for Christmas Lodge J53_J04_S15802_Christmas Lodge_V236981_200705_stage 4.doc Version 1.40 Page 17 staff. The home was found to be meeting the requirements of the fire safety department and the environmental health department. The required safety certificates were in place including a current insurance certificate. Christmas Lodge J53_J04_S15802_Christmas Lodge_V236981_200705_stage 4.doc Version 1.40 Page 18 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) 31, 32, 33, 34 and 36. The service users receive a good standard of care from a staff team that is well trained and motivated. EVIDENCE: The staff recruitment and selection procedure is robust and the required staff records were in place. There was evidence that the required references had been taken up and the required CRB and POVA checks undertaken prior to all new staff taking up their positions. All staff are subject to an induction and statutory training, which includes, health and safety, fire safety, food handling, first aid and infection control. The staff training programme in place includes NVQ, Mental Health Foundation training, medication, abuse awareness and health and safety. The staff rota looked at showed that here are sufficient staff on duty at all times during the day and at night. The staffing levels increase according to the assessed needs of the service users. Staff are employed to carryout domestic and maintenance work. The care staff undertake catering duties. Christmas Lodge J53_J04_S15802_Christmas Lodge_V236981_200705_stage 4.doc Version 1.40 Page 19 Staff meetings are held on a regular basis and records are kept of the outcomes and the actions agreed. All staff are supervised providing them with an opportunity to discuss training needs and any issues of concern. The service users said that the staff looked after them very well and they were always there is they needed to talk. Christmas Lodge J53_J04_S15802_Christmas Lodge_V236981_200705_stage 4.doc Version 1.40 Page 20 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) 37, 38,41 and 42. The service users benefit from a well managed home in which their needs and wishes are put first. EVIDENCE: The registered manager is qualified, competent and experienced to run the home and meet the aims and objectives. The manager has completed the Registered Managers Award and holds a number of associated qualifications. The home has clear policies and procedures in place to assist the manager and staff in meeting the aims and objectives of the home, meeting the needs of the service users and the requirements. Staff meet on a daily basis to discuss the needs of the service users and the arrangements for the day. The home has a health and safety policy and procedure and all staff attend health and safety training. Christmas Lodge J53_J04_S15802_Christmas Lodge_V236981_200705_stage 4.doc Version 1.40 Page 21 There is a quality assurance and quality monitoring system in place, which is based on seeking the views of the service users. One of the registered proprietors undertakes a monthly visit to the home and produces a report on the conduct of the home; copies of these reports are available for inspection. Christmas Lodge J53_J04_S15802_Christmas Lodge_V236981_200705_stage 4.doc Version 1.40 Page 22 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 3 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x 3 x 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 x x 3 x Standard No 31 32 33 34 35 36 Score 3 3 3 3 x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Christmas Lodge Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 x x 3 3 x J53_J04_S15802_Christmas Lodge_V236981_200705_stage 4.doc Version 1.40 Page 23 No 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 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 23 Good Practice Recommendations It is recommended that staff become familiar with the local authorities polcy for reporting allegations or suspicions of abuse. Christmas Lodge J53_J04_S15802_Christmas Lodge_V236981_200705_stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection 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 © 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 Christmas Lodge J53_J04_S15802_Christmas Lodge_V236981_200705_stage 4.doc Version 1.40 Page 25 - 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. 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