CARE HOME ADULTS 18-65
Church Green Lodge Church Lane Sprowston Norwich Norfolk NR7 8ET Lead Inspector
Mr Roger Andrews Unannounced Inspection 22nd December 2005 10:00 Church Green Lodge DS0000035060.V274754.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 Church Green Lodge DS0000035060.V274754.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. Church Green Lodge DS0000035060.V274754.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Church Green Lodge Address Church Lane Sprowston Norwich Norfolk NR7 8ET 01603 411855 01603 411855 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) Norfolk County Council Mrs Carolyn Joanne Graham Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Church Green Lodge DS0000035060.V274754.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. Six (6) service users may be accommodated of either sex who have a learning disability and are aged between 18 and 65 years. The length of stay of a service user shall not exceed 28 days. Where there is a need for this condition to be waived, the provider will consult with the Commission, in advance, to agree and give reasons for any extension. 15th June 2005 Date of last inspection Brief Description of the Service: Church Green Lodge is a six bedded purpose built home offering short term care for up to six adults with learning disabilities. It is located in a residential area in the suburbs of Norwich. All of the accommodation is located on the ground floor. There is car parking to the front of the home and a sizeable enclosed garden to the side and rear. This resource is operated by Norfolk County Council Learning Disability Services. Church Green Lodge DS0000035060.V274754.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection looked mainly at records and at the matters raised in the last inspection report to see what progress had taken place. The majority of the key standards, (those standards the Commission looks at every year), were covered in the previous inspection in June 2005. However, some standards have not been covered as Church Green Lodge offers respite care and they do not apply. At the time of the visit there were six guests staying at Church Green Lodge. The guests were not specifically spoken to in any detail on this visit. However, one guest was having a late breakfast of toast and peanut butter. Another guest was in his room singing along to music. Church Green Lodge has been inspected many times. It is not a home that the Commission receives complaints about. Parents and guests have always commented positively on the service it provides. What the service does well: What has improved since the last inspection?
The weekly checks of the fire system are now being done and recorded which will help protect guests. Old equipment, (commodes), has been replaced Bedroom doors can now be kept open at night if guests prefer, but will close if there is a fire which helps protect guests’ safety and offers them choice if they want to keep their room door open at night. The cupboard where cleaning materials are kept is now kept locked. This also helps guests to remain safe. Church Green Lodge DS0000035060.V274754.R01.S.doc Version 5.1 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. Church Green Lodge DS0000035060.V274754.R01.S.doc Version 5.1 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 Church Green Lodge DS0000035060.V274754.R01.S.doc Version 5.1 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): These standards were not inspected on this occasion. EVIDENCE: Church Green Lodge DS0000035060.V274754.R01.S.doc Version 5.1 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): These standards were not inspected on this occasion. EVIDENCE: Church Green Lodge DS0000035060.V274754.R01.S.doc Version 5.1 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 the following standard(s): These standards were not inspected on this occasion. EVIDENCE: Church Green Lodge DS0000035060.V274754.R01.S.doc Version 5.1 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): These standards were not inspected on this occasion. EVIDENCE: Church Green Lodge DS0000035060.V274754.R01.S.doc Version 5.1 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): 23 Policies for dealing with abuse are up to date and staff have received training on this subject. EVIDENCE: The policy and procedures for whistle blowing and adult protection incidents were looked at. These are sufficiently detailed. The staff have also undertaken training on adult protection procedures. As Church Green Lodge is part of the residential provision of Norfolk County Council Social Services, the procedures are in line with current good practice guidelines. Church Green Lodge DS0000035060.V274754.R01.S.doc Version 5.1 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 Church Green Lodge has a pleasant domestic atmosphere and is clean. EVIDENCE: The home was clean and tidy, pleasantly furnished and was suitably warm for the time of year. The door to the cupboard where cleaning materials are stored was locked. This complies with a requirement made in the previous inspection report. Commodes have also been replaced which complies with a recommendation from the previous inspection report. A call bell was checked at random. This triggered the alarm. However, the system then would not turn off. The manager is seeking professional assistance with this. Church Green Lodge DS0000035060.V274754.R01.S.doc Version 5.1 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): 34 & 35 Training is in place on a variety of topics and a record is now kept. Evidence of good recruitment practice is now kept on the premises, but needs the additional evidence of an enhanced Criminal Records Bureau check being carried out. EVIDENCE: The records on staff identified in schedule 4 of the Care Homes Regulations 2001 are now kept at the home. However, evidence of an enhanced Criminal Records Bureau check is required. See requirement. Norfolk County Council who is the employer undertakes these checks. They need to provide the manager of Church Green Lodge with evidence for her on-site records. A record of staff training is now kept in line with a requirement in the previous inspection report. Recent training includes health and safety, medicines for residential homes, food hygiene and challenging behaviours. The latter satisfies a requirement made in the previous inspection report. A member of staff has just completed her NVQ 2. Two staff are currently undertaking NVQ 3. The manager has completed her NVQ 4. Church Green Lodge DS0000035060.V274754.R01.S.doc Version 5.1 Page 15 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): 41 & 42 Fire records and fire system checks were up to date. Financial records should be checked regularly to ensure they are correct. EVIDENCE: The fire records were checked. Weekly tests of the fire system are being carried out and recoded. This complies with a requirement made in the previous inspection report. The fire alarm system and emergency lighting system was serviced in November 2005. Automatic closure devices have now been fitted to all bedrooms so that they can remain open, but will close in the event of the fire system being set off. Fire safety and evacuation training has taken place since the last inspection was carried out. Several financial records relating to guests’ monies were looked at. On one record an entry had been overwritten and an ‘incorrect’ entry made. In this case the entry was in favour of the guest. However, there was no explanation for the change in the record. Records should not be overwritten once entered.
Church Green Lodge DS0000035060.V274754.R01.S.doc Version 5.1 Page 16 Any change should be recorded in a fresh entry and an explanatory note attached to the record. The record should also be checked, (e.g. when each guests returns home), to ensure the record is correct. See requirement. Church Green Lodge DS0000035060.V274754.R01.S.doc Version 5.1 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 Standard No Score 1 X 2 X 3 X 4 X 5 X INDIVIDUAL NEED AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 2 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 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X X X X X 2 3 X Church Green Lodge DS0000035060.V274754.R01.S.doc Version 5.1 Page 18 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 YA34 Regulation 17 Requirement Evidence of an enhanced Criminal Records Bureau check being carried out on staff is required to be kept on the staff file. Financial records must not be overwritten and records must be checked to ensure they are correct. Timescale for action 01/02/06 2 YA41 17 01/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Church Green Lodge DS0000035060.V274754.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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