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Inspection on 08/06/06 for Church Green Lodge

Also see our care home review for Church Green Lodge for more information

This inspection was carried out on 8th June 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 no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Church Green Lodge offers a bright homely atmosphere for guests to enjoy their stay. Bedrooms and communal areas are pleasantly decorated. Guests can decide with staff about trips out such as going to the beach. Information about guests is regularly updated before they come and stay. The guests always say they like coming to stay at Church Green Lodge and they like the staff. The premises allow access to guests who need to use special equipment such as a wheelchair.

What has improved since the last inspection?

Criminal Records Bureau checks are being renewed on all staff which will help to protect guests. A detailed business plan has been developed to set out how Church Green Lodge should develop its service to guests.

What the care home could do better:

Weekly checks of fire points must be carried out and recorded so that guests are, as far as possible, protected. A policy on the use of restraint needs to be put it place to give guidance to staff. Any restraint needs to be recorded in detail and a form could be developed to ensure this. Redecoration should take place in line with the suggestions made in the May 2006 regulation 26 visit report.A process which reviews the quality of care, training and the environment needs to be put into place to ensure standards are consistently upheld and improved. The formal supervision of staff needs to be put in place. This should occur every two months as recommended by the National Minimum Standards.

CARE HOME ADULTS 18-65 Church Green Lodge Church Lane Sprowston Norwich Norfolk NR7 8ET Lead Inspector Mr Roger Andrews Unannounced Inspection 8th June 2006 01:00 Church Green Lodge DS0000035060.V299635.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 Church Green Lodge DS0000035060.V299635.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. Church Green Lodge DS0000035060.V299635.R01.S.doc Version 5.2 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 Position Vacant (Application Pending) Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Church Green Lodge DS0000035060.V299635.R01.S.doc Version 5.2 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. 22nd December 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 Learning Difficulty Services. Typically guests will stay for a few days , a weekend or a full week. Some stays may be longer. The fees for the respite service will vary depending on individual circumstances of guests and their families. Church Green Lodge DS0000035060.V299635.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 and covered the key National Minimum Standards. Discussion took place with the manager, the staff on duty and the guests currently staying at Church Green Lodge. Records were looked at and some guests had completed a questionnaire before the inspection took place. A tour of the building also took place. Church Green Lodge offers a good service to its guests. It is not a service that the Commission receives complaints about. What the service does well: What has improved since the last inspection? What they could do better: Weekly checks of fire points must be carried out and recorded so that guests are, as far as possible, protected. A policy on the use of restraint needs to be put it place to give guidance to staff. Any restraint needs to be recorded in detail and a form could be developed to ensure this. Redecoration should take place in line with the suggestions made in the May 2006 regulation 26 visit report. Church Green Lodge DS0000035060.V299635.R01.S.doc Version 5.2 Page 6 A process which reviews the quality of care, training and the environment needs to be put into place to ensure standards are consistently upheld and improved. The formal supervision of staff needs to be put in place. This should occur every two months as recommended by the National Minimum Standards. 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.V299635.R01.S.doc Version 5.2 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.V299635.R01.S.doc Version 5.2 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): 2 The quality outcome for these standards is excellent Guests are properly assessed prior to commencing stays at Church Green Lodge. EVIDENCE: Information is gathered on prospective guests prior to staying at Church Green Lodge and new guests come for a preliminary visit, (usually with their parent or carer), followed by a visit to have tea and spend an evening there and, finally, an overnight stay. Three of the guests chatted with during the inspection were there on their second visit and were joining the other guests for tea. Many of the guests who stay at Church Green Lodge are known to the staff from previous stays. In line with previous recommendations the staff now update their information on each guest prior to each stay commencing. This is good practice. These update records are kept in a specific file for easy access. Church Green Lodge DS0000035060.V299635.R01.S.doc Version 5.2 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): 6, 7 & 9 The quality outcome for these standards is excellent. Appropriate and up to date information is on file for each guest including risk assessments. Guests are involved in the making of day-to-day lifestyle choices. EVIDENCE: Each guest has a file of important information, though this is not as detailed a care plan as would be expected if the guests lived here on a permanent basis. Nevertheless, the information is relevant and covers key areas such as ability to carry out personal care tasks like washing and bathing, eating, medical issues, (such as allergies), and work and leisure interests. As already noted, this information is updated prior to each stay. Daily notes are also maintained which give a good impression of each guests stay at Church Green Lodge. In some instances communication books are used between Church Green Lodge, home and day care services. In one instance where events are recorded in a communication book for one guest there is a Church Green Lodge DS0000035060.V299635.R01.S.doc Version 5.2 Page 10 clear instruction to the staff that recording the behaviour of the guest in the book must not be made to seem like a threat. Guests are clearly involved in decision-making during their stay which will include outing venues, what to eat and in-house activities. As guests are typically here for a holiday break involvement on a more formal basis is not appropriate. A personal risk assessment was noted on each of the three files randomly viewed during the inspection. Church Green Lodge DS0000035060.V299635.R01.S.doc Version 5.2 Page 11 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 The quality outcome for these standards is excellent. Guests enjoy a varied stay with plenty of outings and they are involved in dayto-day decisions about what to wear, where to go and what to eat. EVIDENCE: Daily records show guests being involved in regular activities. Examples include ‘out to Wroxham’, ‘out to the beach for a walk’, ‘made some cheese scones’ and ‘listened to T.V. after a trip out to the beach’. During their stay most guests will attend the local day services centre, which is just across the road from Church Green Lodge. Church Green Lodge has its own transport so that evening and weekend trips can take place. The staff have to liaise with another service periodically to negotiate the use of a vehicle with a tailgate lift when guests who require wheelchair access to vehicles are staying. During the inspection guests were watching television and playing snooker prior to tea being served. There are a range of games and in-house activities and guests have access to satellite television in both lounges. They also have televisions and music equipment in their bedrooms. Church Green Lodge DS0000035060.V299635.R01.S.doc Version 5.2 Page 12 Guests can have regular contact with family if they wish, e.g. via telephone and there is a public telephone available in the large alcove along the corridor. Many of the guests already know each other as a result of earlier stays or by virtue of attending the same day services. The staff have undertaken training during the previous twelve months on personal relationships. The menu is publicised in the kitchen and any special dietary needs for individual guests are noted on a card. Guests can make hot drinks depending on ability. The new guests arriving for their second visit were all offered a hot drink on arrival by the staff. They seemed pleased to learn they were having beef burgers for tea. One of the guests who has been staying for several days said he liked the food. Meals are generally taken around the large table in the kitchen/dining area, though it was noted in the records that one guest, (not a current guest), was given the option of having his meals in the lounge due to the behaviour of another guest at that time. On some occasions guests will have meals out as part of their trips and outings. There is also bar-b-q equipment in the sizeable garden. Fresh fruit was available in the kitchen in fruit bowls as has been the usual practice at Church Green Lodge for some time. In their questionnaires guests gave differing responses about being able to go shopping, though this will depend on the length and specific days of their stay. Church Green Lodge DS0000035060.V299635.R01.S.doc Version 5.2 Page 13 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): The quality outcome for these standards is good. Personal care support is geared to the individual and guests are able to be as independent as possible. Medication is properly stored and records of administration are up to date. EVIDENCE: The help individual guests require is documented in their personal files as well as healthcare issues, though as guests only come for short stays of a few days or a week, any ongoing health concerns are followed up by their own doctors and specialists when they are at home. Whilst they are staying at Church Green Lodge the local surgery can be used and this is located next door to the property. Guests are encouraged to do those personal care tasks that they would normally do for themselves at home and comments such as “can make choices about dressing” were noted on care plans. One guest was “assisted to wash their hair, but they declined a shower”. One guest was reported to be looking after his finances during his stay. Church Green Lodge DS0000035060.V299635.R01.S.doc Version 5.2 Page 14 Medication is stored in a purpose built metal cabinet in the office which is kept locked when not in use. Medication comes in the form of a cassette case prepared by either the pharmacist or the guest’s carer. The medication is documented on a medication record including the numbers of tablets and staff initial any administration on this form. There is still some internal discussion on the final shape the medication procedure is going to take at Church Green Lodge. Church Green Lodge DS0000035060.V299635.R01.S.doc Version 5.2 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 the following standard(s): The quality outcome for these standards is excellent. Complaints are properly dealt with and recorded and staff receive training on adult protection issues. EVIDENCE: Over the last twelve months there have been three complaints made to the manager. None of these are serious in nature and the complaint record shows that they were properly addressed and dealt with and followed up in writing to the guests concerned with the outcome and any changes made. There was also a recent letter of commendation on file from a professional colleague complimenting the staff on the excellent work they had done with a guest who stayed at Church Green Lodge for a short period as part of a transition to a new permanent home. Staff have undertaken ‘vulnerable adults at risk’ training during the previous twelve months as part of the training programme. Church Green Lodge DS0000035060.V299635.R01.S.doc Version 5.2 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 the following standard(s): 24, 25, 27 & 30 The quality outcome for these standards is Excellent. The premises provides accommodation of a good standard and provides a welcoming atmosphere. EVIDENCE: Church Green Lodge is a single storey building allowing good access to all areas including those guests who require wheelchair access. There are disabled access bathroom and toilet facilities including an adjustable Arjo bath. There is a choice of communal areas, which comprise two comfortable lounges equipped with domestic style furniture, television and music equipment and an activity room with pool table and a range of games equipment. All bedrooms are single and have a television and a radio/CD player. Bedrooms are pleasantly decorated and all have views onto the rear garden. The Regulation 26 visit conducted on 16th May 2006 by a representative of the county Council identified a need for some general redecoration, especially external window frames. See recommendation. Church Green Lodge DS0000035060.V299635.R01.S.doc Version 5.2 Page 17 The garden is quite large and well kept and has some garden tables, though these look as if they have reached the point where they need replacing. All areas were clean, tidy, free of unpleasant odours and the cupboard containing cleaning materials was locked. One call bell was randomly tested and was in working order. No obvious hazards to guests’ safety were noted during the walk round the building. Natural lighting is good in all areas. Church Green Lodge DS0000035060.V299635.R01.S.doc Version 5.2 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 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 & 36 The quality outcome for these standards is good. Staffing is in line with the support needs of guests and staff receive varied training opportunities relevant to the work they undertake. EVIDENCE: The staff have undertaken a variety of training over the previous twelve months. Examples include emergency first aid, food hygiene, challenging behaviour, person centred planning, signalong and report writing. Two staff are currently undertaking NVQ training and four relief staff are due to commence NVQ training from the end of June 2006. In addition to the manager one other member of staff is commencing NVQ training at level 4 from September 2006. Two staff have completed NVQ 2 training. The staff group comprises of a mixture of full time, part time and relief staff, though some of the relief staff have worked at Church Green Lodge for some time and good relationships are in place with the guests. The staffing levels are adjusted according to the needs of the guests in residence at any particular time. There has been a move towards accommodating guests with more challenging behaviours recently, though this is still in a trial phase. Additional staffing resources have been allocated for Church Green Lodge DS0000035060.V299635.R01.S.doc Version 5.2 Page 19 these periods, though it does impact on the availability of the resource for its ‘usual’ guests. Discussion took place with the manager about the need to develop a policy on the use of restraint in the light of guests’ with more challenging behaviours being accommodated. A document to allow any instances of restraint to be comprehensively recorded also needs to be formulated. See requirement. Staff meetings are held periodically, though there is a small staff group and a considerable day-to-day exchange of information. There are clear channels of communication and staff have individual pigeon holes for circulars, training courses and other useful documentation. The manager reported that supervision had lapsed a little and needs to be reestablished on a regular basis and documented. See requirement. Some random staff files were viewed. All staff are now having Criminal Records Bureau checks renewed. The manager is aware that evidence of these checks must be held on site in staff files. Church Green Lodge DS0000035060.V299635.R01.S.doc Version 5.2 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 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): The quality outcome for these standards is adequate. A quality assurance process needs to be put in place. Safety checks such as weekly fire checks must be undertaken. EVIDENCE: The manager has recently returned to his post following a period of secondment to another resource and is, therefore, resettling back into this role. His application to be registered is pending, and is not likely to be problematic. The manager is currently undertaking training at NVQ level 4. Church Green Lodge always gives the impression of a happy environment and guests and relatives are traditionally positive in the views they express about the service it offers. Staff very much enjoy working there, though some have fears about the effects that catering for guests with more challenging behaviours may have. Church Green Lodge DS0000035060.V299635.R01.S.doc Version 5.2 Page 21 The fire system and equipment has been serviced. The record of weekly checks shows that these are not always taking place. A system needs to be developed to ensure this occurs or quickly picks up when such checks are not carried out as this is an important health and safety issue to aid fire prevention. Failure to effectively carry out important health and safety checks will affect the overall quality rating that Church Green Lodge can achieve. See requirement. A record is kept of any money being looked after on behalf of a guest. Two randomly viewed samples were in order. Guests usually only bring a small amount of money with them for outings. A formal quality assurance process needs to be developed. See requirement. However, a detailed business plan has been drawn up and this was looked at briefly during the inspection. A representative of the county council visits Church Green Lodge to check on the running of the home. S/He produces a report, a copy of which is shared with the Commission for Social Care Inspection. The previous inspection report by the Commission for Social Care Inspection is displayed on the notice board in the kitchen. Church Green Lodge DS0000035060.V299635.R01.S.doc Version 5.2 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 Standard No Score 1 X 2 4 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 4 25 4 26 X 27 4 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 4 2 X X 2 X Church Green Lodge DS0000035060.V299635.R01.S.doc Version 5.2 Page 23 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 YA32 Regulation 13 Requirement It is required that the use of restraint on any service user is guided by a written policy and that any such instances of restraint are fully recorded. It is required that staff are formally supervised on a regular basis as determined in the National Minimum Standards It is required that weekly checks of the fire system are carried out and recorded. A process for reviewing the quality of care needs to be developed and put into place. Timescale for action 31/08/06 2 YA36 18 31/08/06 3 YA42 23 30/06/06 4 YA39 24 30/10/06 Church Green Lodge DS0000035060.V299635.R01.S.doc Version 5.2 Page 24 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 YA24 Good Practice Recommendations General redecoration should be carried out in line with the May 2006 regulation 26 visit report. Church Green Lodge DS0000035060.V299635.R01.S.doc Version 5.2 Page 25 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 © 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 Church Green Lodge DS0000035060.V299635.R01.S.doc Version 5.2 Page 26 - 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!