Inspection on 12/06/09 for Colleton Lodge

This inspection was carried out on 12th June 2009.

CQC found this care home to be providing an Adequate service.

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

Colleton Lodge 19/06/08

Similar services:

Trevaylor Manor

Stallcombe House

Stroud Lodge

The Woodmill

Woodland Vale

Bolealler House

Claremont Nursing Home

Althea Park House

Extracts from inspection reports are licensed from CQC, this page was updated on 25/11/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Colleton Lodge Colleton Crescent Exeter Devon EX2 4DG     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Sue Dewis     Date: 1 8 0 6 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 31 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 31 Information about the care home Name of care home: Address: Colleton Lodge Colleton Crescent Exeter Devon EX2 4DG 01392275456 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Colleton.Lodge@Guinness.org.uk Guinness Care and Support Ltd Name of registered manager (if applicable) Type of registration: Number of places registered: Conditions of registration: Category(ies) : care home 10 Number of places (if applicable): Under 65 Over 65 0 mental disorder, excluding learning disability or dementia Additional conditions: 10 The maximum number of service users who can be accommodated is 10. The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: Mental disorder (Code MD) Date of last inspection Brief description of the care home In October 2007 Devon Community Housing Society and Guinness Care and Support amalgamated with Guinness Care and Support being registered as the providers of this service in December 2007. The Home provides accommodation and support for up to 10 adults who have mental health problems. Colleton Lodge is an attractive, large detached building standing in its own grounds Care Homes for Adults (18-65 years) Page 4 of 31 Brief description of the care home near the centre of Exeter. It has large gardens and its own small car park. The home has an airy entrance hall, with two lounges and a dining room. There are also three single bedrooms on the ground floor, and the homes main kitchen. The first floor includes seven single bedrooms with some WCs and two bathrooms. There is a WC and bath on a mezzanine landing between the ground and first floors. A basement area contains an office, food stores, the homes laundry and a smoking lounge. Among the stated aims of the home are to provide a safe, supportive and structured environment where individual needs of the service user will be met and optimum independence will be encouraged and supported. All places at this home are purchased under a block contract with Devon County Council at a set fee of 570 pounds per place per week. Copies of the homes inspection reports are available in the entrance hall. Care Homes for Adults (18-65 years) Page 5 of 31 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: This unannounced visit took place over 10 hours, on 2 days during the middle of June 2009. The home had been notified that a review of the home was due and had been asked to complete and return an AQAA (Annual Quality Assurance Assessment). This shows us how the home has managed the quality of the service provided over the previous year. It also confirms the dates of maintenance of equipment and what policies and procedures are in place. Information from this document was used to write this report. Although only one inspector undertook this inspection, throughout the report there will be reference to what we found and what we were told. This is because the report is Care Homes for Adults (18-65 years) Page 6 of 31 written on behalf of the Care Quality Commission. During the inspection 3 people were case tracked. This involves looking at peoples individual plans of care, and speaking with the person and staff who care for them. This enables the Commission to better understand the experience of everyone living at the home. As part of the inspection process CQC likes to ask as many people as possible for their opinion on how the home is run. We sent questionnaires out to people living at the home and staff. At the time of writing the report, responses had been received from 6 people living at the home and 8 staff. Their comments and views have been included in this report and helped us to make a judgement about the service provided. During the inspection 1 person living at the home was spoken with individually and 5 in a group setting, as well as observing staff and people living at the home throughout the day. We also spoke with 2 staff individually, a further 2 in a group setting and the manager. A full tour of the communal areas of the building was made and a sample of records was looked at, including medications, care plans and staff files. What the care home does well: What has improved since the last inspection? What they could do better: Care plans need more detail to ensure staff have sufficient information on how the needs of individuals are to be met. Personal information relating to any individual should be kept separately. Recordings should be non-judgemental and provide evidence that identified needs have been met. There needs to be more opportunities for people to develop skills in order to be able to achieve their personal goals. The complaints procedure showing the contact details for Guinness Care and Support should be displayed so that everyone know who to contact should they have any concerns. The standard of decoration in many areas of the home is poor especially toilets, bathrooms, stairs and landings. Staffing levels need to be sufficient and specialist training provided in order to ensure Care Homes for Adults (18-65 years) Page 8 of 31 that peoples identified needs and goals can be met. Evidence should be sent to the Commission showing that equipment at the home has been correctly maintained and serviced. The manager needs to be registered with the Commission. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Adults (18-65 years) Page 9 of 31 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 10 of 31 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is a good assessment and admission process in place, which means that people thinking of moving into the home can be sure that their needs will be met. Evidence: There have been no new admissions to the home for some time. However, one person who is thinking of moving into the home is currently spending some time each week at the home on a regular basis. This is to allow them to get to know the home and the home to get to know them and their needs. We saw copies of assessments completed by their current placement and a copy of a provisional care plan drawn up by the home. All of this information is easily accessed by staff at the home. Some information relating to their time at Colleton Lodge is recorded whilst the person is there. There were mixed responses from people about whether they felt they had had enough information about the home, three people felt that they did and three people felt that Care Homes for Adults (18-65 years) Page 11 of 31 Evidence: they did not. There were similar mixed responses about whether people had been asked if they wanted to move into the home. Two people said that they had been asked, while four said that they had not. Care Homes for Adults (18-65 years) Page 12 of 31 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People benefit from living in a home where their daily choices and decisions are generally respected. Risks to their well-being and safety are assessed but care plans are not sufficiently detailed to ensure that their identified needs or areas of risk are fully met by all staff. Not all personal information is recorded appropriately. Evidence: We looked at three peoples care files to help us judge how care is planned and delivered. Care files contain a lot of detailed and useful information about peoples support needs that has been provided by heath and social care professionals. There are good summaries of peoples care needs and individual risks, including triggers. Early warning signs of deterioration are also on the files. The local Recovery and Independent Living Team help people to plan individual goals and provide a great deal of support to people living at the home. On the day of the visit one person went to lunch with someone from this team. Care Homes for Adults (18-65 years) Page 13 of 31 Evidence: The homes care plan format is being reviewed and updated. There was no evidence to show that the current plans are regularly reviewed and 2 of the plans had not been reviewed since since January 2008. The plans in use at the moment include details of individual goals and action for staff to take to assist people to meet their goals. However, actions were not specific and there were no timescales for achieving goals. For example, the aim for one person was to optimise potential for living in a more independent setting. The action for staff was to encourage to use community facilities. However, there was no detail about which facilities the person may want to access or the support they might need to achieve this. Another care plan stated that X can become verbally abusive, but there were no instructions to staff on how to deal with this. Care plans need to be as informative as possible to ensure that all staff working at the home can deliver a consistent service to the people living there. Five surveys that were returned to us indicated that people can make decisions about what they do each day and can do what they want to do at any time. One person felt that they could not make decisions or do what they wanted to at any time. Daily recordings are made for each person living at the home. However, not all were appropriate and some were judgemental. For example, wouldnt hand over money to put back and wouldnt go to bed. There was little evidence of staff spending time with people meeting their identified aims/needs. The home also keeps a handover book in which personal information about everyone is written. All personal information about individuals should be recorded separately so that they can see their own records without seeing personal information about other people. These concerns had been highlighted at the previous visit. Care Homes for Adults (18-65 years) Page 14 of 31 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. While some people receive support to develop personal skills and achieve their personal goals, there is not enough support from within the home to ensure that all have the opportunity to do this. Daily routines are flexible and the meals provided are varied and satisfactory. Evidence: The local Recovery and Independent Living Team visit several people at the home on a weekly basis to enable them to access the community, to develop their independent living skills and generally build their confidence. Some people are motivated and independently access the local community and activities. Some people work in a voluntary capacity at a local garden centre and Care Homes for Adults (18-65 years) Page 15 of 31 Evidence: charity shops. People use the local pubs and shops frequently. People told us that they like to visit town regularly and enjoy visits to the Quay with staff for a coffee. There are some activities arranged within the home including film evenings, music and Karaoke sessions and one staff member runs a poetry group. However, people living at the home told us that most of their time was spent sitting around doing nothing. Seven of the staff that returned forms felt that low staffing levels restricted the amount of time staff were able to spend with with individuals going out into the community. This is particularly concerning as the main focus of the work at the home (as specified in care plans) is to enable people to access community facilities in order to increase their potential for living independently. We sat with people during lunch, and they told us that they could chose what they wanted for some meals and were supported to plan, shop for and prepare meals on a regular basis. One person said via their survey form that the food is wonderful, one person said that they would like more fresh food and another said they would like better food. Since the last visit an area in the kitchen has been made available to individuals where they can make hot drinks. The manager told us that snacks were now available at any time and that people are able to request menu changes. Care Homes for Adults (18-65 years) Page 16 of 31 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live at Colleton Lodge are supported in their personal and health care needs in a way that suits them. Systems for the administration of medicines are well managed. Evidence: People living at the home manage their own personal care with support and prompting from staff when needed. Care plans generally identify what kind of prompting and monitoring people need. We saw that people choose their own clothes, hairstyles and make up, and their appearance reflects their personality. This helps to maintain peoples dignity and independence, and encourages them to express themselves. Records that were looked at show that people have access to various health professionals, such as GP, well woman clinics, specialist nurses and the community mental health team, including psychiatrists. The home has established close links with the local Recovery and Independent Living Team who visit regularly to support several individuals. Care Homes for Adults (18-65 years) Page 17 of 31 Evidence: We saw that the home stores medication in a secure manner and has in place a good system to record the receipt of medicines into the home. We also saw that there is a system in place to record when medicines are taken out of the home. The home now has clear individual protocols on each persons file for how medicines prescribed to be administered when required are to be used. Staff told us that they always discuss the use of use medication and can also contact the person on call for advice. All administrations of medicines had been recorded on the Medication Administration Record charts. Staff told us and records show that they had received training in the administration of medicines. Care Homes for Adults (18-65 years) Page 18 of 31 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples views are listened to and acted upon, and adequate procedures are in place to ensure that people are protected from abuse. Evidence: There is no complaints procedure displayed at present. This is because the current owners have told the acting manager to remove all notices/letters with the previous owners name on them, but they have not yet supplied information complaint with their name and address on. However there is a copy of the complaints procedure in the homes Statement of Purpose which needs updating to show the details of the new Commission. One person indicated on their survey form that they did not know how to make a complaint, but the other five said that they did. There are regular Service User Group meetings held every four weeks run by Exeter Volunteer services. This group enables people to raise any concerns they may have which are then passed on to staff of the home if people agree. Three staff files were looked at and they did not contain all the information that would show that checks had been completed to ensure that new staff were suitable to work with vulnerable people (see Section 7 Staffing). All of the four staff that were spoken with had received formal training in POVA (Protection of Vulnerable Adults) issues and Care Homes for Adults (18-65 years) Page 19 of 31 Evidence: were able to discuss different forms of abuse and said that they would report any suspicions they had. They were not all clear however, about who they would report any concerns to, outside of the home. Care Homes for Adults (18-65 years) Page 20 of 31 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has a poor standard of decor in many areas and does not provide individuals with a homely and comfortable environment in which to live. Evidence: Since the last visit some progress has been made for completing some of the much needed environmental improvements at the home. The stairs and entrance hall of the home have recently been re-carpeted, although the carpet was heavily soiled in places. The basement area is still in need of re-decoration, as is the smoking/meeting room, which is very unpleasant with chairs being stained and dirty. Paintwork is chipped along hallways and walls are dirty, landing areas are dark and dismal. The home is in general need of refreshing and updating. The overall feel was somewhat depressing. This is concerning as current thinking suggests that peoples environment impacts on their state of mind and well being. Everyone has their own bedroom and several people told us they particularly liked their rooms. We were invited to visit one bedroom and could see that their space had been personalised to the taste of the individual. Care Homes for Adults (18-65 years) Page 21 of 31 Evidence: Bathroom and toilet facilities are adequate but basic and not very pleasant. The bathrooms are institutional and are not condusive to a pleasant and relaxing experience. The toilets were smelly and the floors were very stained and one had paint flaking from the ceiling. The communal dining room and lounge are bright and pleasant. New covers for the seating and curtains for in the lounge have been purchased. There is a quite room next to the lounge which has a computer for people to use but it is waiting to be connected to the internet. There is a mature garden around the house that has been cleared by outside contractors, who will be maintaining it on a regular basis. The manager said that they hope that staff and people living at the home will be able to maintain some of the garden. The home now employs part time domestic staff who keeps the home generally clean and as free from offensive odours as possible. However, this is difficult due to the poor state of repair of the building. Individuals are still encouraged to keep their own space clean and to help with domestic duties around the home. During the visit one person was helping to vacum the hallway. People are also encouraged to do their own laundry. The laundry room is large and quite well equipped. It has recently been re-plastered but not finished so that the walls are not impermeable or easy to clean. Staff told us and records confirmed that they have received training in infection control. Disposable gloves and aprons were readily available. Care Homes for Adults (18-65 years) Page 22 of 31 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Some people living at the home are unlikely to receive the support they need, as staff do not have the time or the specialist training they need to care for people with mental health issues. Evidence: There have been issues relating to staffing at the home for some time, with high levels of bank/agency staff being used. This has improved a little recently and the manager was due to interview for more permanent staff the week following this visit. However, one member of bank staff commented via a survey form There has been erratic continuity over staffing which makes it difficult to maintain consistency. The staff group is relatively new and few staff have any specialist training in caring for people with mental health issues. There are two staff on duty every shift plus the manager and domestic during the day. The manager told us that they were able to call in extra staff if they were needed. However, this does not seem to happen on a regular basis and this means that there are limited opportunities for staff to go out with individuals (see also Section 3 Lifestyle). One staff member commented on their survey form ...(need) more staff to enable people to be taken out more often and not leave the home short staffed. Care Homes for Adults (18-65 years) Page 23 of 31 Evidence: People that we spoke with during the inspection felt that staff treated them well and understood any restrictions placed upon them. However, one person told us that everything had gone to pot due to there not being enough staff. Two people told us on their survey forms that staff did not always treat them well, but gave no specific incidents. Three staff files were looked at during this visit. Not all the required information was available to show that the providers have had ensured that staff were fit to work with vulnerable people. One file did not contain a satisfactory CRB (Criminal Records Bureau) check. The home later provided evidence that a check had been obtained but a copy had not been passed to the home. The other two files contained all the required information. Staff told us and records confirmed that they had received a variety of training, including Moving and Handling, Infection Control, De-escalation and Breakaway and Medication Administration. The manager told us that they were waiting for dates for a course for staff on Mental Health Awareness and Rehab and Recovery. Staff are able to work for a recognised care qualification (NVQ 2) when they have completed their induction. However, placements are limited and one staff member told us that their application to do an NVQ had been unsuccessful. Care Homes for Adults (18-65 years) Page 24 of 31 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live at Colleton benefit from a service that is generally well run and there are systems in place to ensure their views are considered in reviewing the care and support offered. However, low staffing levels, a lack of specialist training, care plans that do not contain sufficient information for staff and the fact that the manager has still not registered with the Commission could lead to inconsistent care being provided. Evidence: The manager of the home has been in post for almost a year, but they are not yet registered with the Commission. The manager told us that they had sent off their application to GCS who were to send this along with the fee to the Commission. Staff at the home told us that they felt well supported by the manager and this was repeated on many of the survey forms that were returned to us. There are issues within the home that fall within this outcome group that have been outlined elsewhere, these include staffing levels and a lack of specialist training for Care Homes for Adults (18-65 years) Page 25 of 31 Evidence: new staff. This coupled with care plans that do not contain good directions to staff on how to meet peoples needs could lead to inconsistent care. Each month a service user group is held by a visiting advocate and excludes staff. We were told that people have an opportunity to discuss issues in confidence but that where appropriate, issues are discussed with the manager and actioned if necessary. A record of the meetings was seen and demonstrated that peoples views and ideas had been listened to and acted upon. The manager told us that questionnaires had been sent out to people living at the home and when responses had been received a report would be produced. The manager gave us a report showing how the requirements and recommendations from the previous visit had been addressed. As part of reviewing the quality of the care provided, the managers line manager from Guinness Care and Support visits the home unannounced every month. They talk to people living at the home and staff about the quality of the service and provide a report on this visit to the manager and senior Guinness Care and Support managers. The manager told us that there was no-one living at the home that is subject to a deprivation of liberty authorisation. We saw no evidence to show that anyone living at the home is having their liberty deprived without an authorisation. The AQAA (Annual Quality Assurance Assessment) submitted prior to the visit, did not provide evidence that Colleton Lodge complies with health and safety legislation in relation to maintenance of equipment. The home must send copies of certificates showing the dates of maintenance of equipment. This has been an ongoing issue from several visits. The storage of hazardous substances, health and safety checks and risk assessments were satisfactory. Accident and incident records were found to be accurate and up to date. Policies and procedures are not always inspected during the visit but the information provided on the AQAA helps us form a judgement as to whether the home has the correct policies to keep people living and working at the home safe. Information provided by the home, evidenced that policies and procedures are in place and along with risk assessments are reviewed regularly and updated where necessary, to ensure they remain appropriate and reduce risks to people living and working at the home. So that the risk of burning from hot surfaces is minimised, radiators within the home have been risk assessed and there is a plan to cover them all. All windows above Care Homes for Adults (18-65 years) Page 26 of 31 Evidence: ground floor level are fitted with restrictors, in order to minimise the risk of anyone falling from these windows. The AQAA (Annual Quality Assurance Assessment) submitted prior to the visit indicates that in order to improve the service the home intends to be more focused on the rehabilitation of individuals, to complete the interior and exterior renovations to the home, to provide specialist training to staff and to ensure that people enjoy a fulfilling and good quality life. Care Homes for Adults (18-65 years) Page 27 of 31 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 28 of 31 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 2 3 6 6 10 Care plans should include sufficient direction to staff in order to ensure peoples identified needs can be met. Daily recordings should be non-judgemental and provide evidence where identified needs have been met. All information about an individual should be kept separately, so if they wished to see information about themselves they did not have access to information about other people. People should have more opportunities to be able to meet their identified goals. A complaints procedure showing the correct contact details of the owners of the home and of the Commission should be displayed, so that people know who to raise concerns with. Staff should be available in sufficient numbers to ensure that peoples identified needs and goals can be met. Staff should have suitable specialist training in order to ensure they have the skills and knowledge to meet the needs of individuals. The manager should submit an application to register with Page 29 of 31 4 5 13 22 6 7 32 35 8 37 Care Homes for Adults (18-65 years) the Commission as soon as possible. 9 42 Evidence that equipment has been correctly serviced and maintained should be submitted to the Commission as soon as possible. Care Homes for Adults (18-65 years) Page 30 of 31 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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