Inspection on 12/06/07 for Colwill Lodge

This inspection was carried out on 12th June 2007.

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

Colwill Lodge 20/10/05

Colwill Lodge 05/05/05

Colwill Lodge 05/10/04

Colwill Lodge 22/04/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Colwill Lodge Colwill Lodge Leypark Walk Plymouth Devon PL6 8UE Lead Inspector Wendy Baines Unannounced Inspection 12 June 2007 10:30 Colwill Lodge DS0000031052.V311603.R02.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 Colwill Lodge DS0000031052.V311603.R02.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. Colwill Lodge DS0000031052.V311603.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Colwill Lodge Address Colwill Lodge Leypark Walk Plymouth Devon PL6 8UE 01752 768646 01752 776255 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) Plymouth City Council Andrew Rowing-Parker Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Colwill Lodge DS0000031052.V311603.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service Users Age 18 - 65. Service Users with Learning Disabilities who may also have physical disabilities or sensory impairment. 20th October 2005 Date of last inspection Brief Description of the Service: Coldwill Lodge is a respite care home that provides short-term personal care and accommodation for up to 12 people who have a learning disability and who may also have a sensory impairment or physical disability. It is owned by Plymouth City Council and provides a respite service for approximately 50 to 60 people overall. The home is located at the end of a Cul–de-sac in the residential area of Estover in Plymouth. This is close to pubs, shops and other local amenities. The home was opened in 1990 and is a detached bungalow. The home has ten single bedrooms and two shared rooms, none of which have en suite facilities. There are, however, bathing and toilet facilities close to bedrooms and communal areas. There are two lounge areas, one of which is designated as a quiet room, a dining room that is also used for various activities, and a sensory room. There is a call bell system throughout the home. There are attractive, spacious gardens that are accessible to service users. Colwill Lodge DS0000031052.V311603.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is a summary of a cycle of Inspection activity at Colwill Lodge since the last inspection visit on the 20th October 2005. For the purpose of this report the term ‘ Service user’ will be used to describe the people using the service. To help CSCI make decisions about the service the Provider gave us information in writing about how the home is run; any documents submitted since the last inspection were examined along with the records of what was found at the last visit; a site visit took place over two days, totaling 9 hours with no prior notice being given to the home as to the date and timing. Discussions were held with management and staff on duty; various records were sampled, such as care plans and risk assessments; and a tour was made of the house and garden; time was spent with people using the service and the inspector was able to talk with, and observe the staff on duty. A sample group of service users were selected and their experience of care was tracked through records and discussions with staff and management from the early days of their admission to the current date, looking at how well the home understands their needs and the opportunities and lifestyles they experience whist staying at Colwill Lodge. Where possible time was then spent with these service users, and questionnaires were sent to their advocates, care managers and other specialist services. This approach hopes to gather as much information about what the experience of living at the home is really like, and makes sure that service users views of the home forms the basis of this report. The Registered Manager was on annual leave, and was therefore unable to be present during the inspection visit. However, the Inspector met with three duty managers all of whom were able to fully assist in the inspection process. Colwill Lodge DS0000031052.V311603.R02.S.doc Version 5.2 Page 6 What the service does well: The home undertakes good pre-admission planning, which ensures that anyone using the service will have his or her needs met. New service users and their representatives are provided with sufficient information to enable them to make an informed choice about whether or not to use Colwill Lodge for the purpose of respite care. The home undertakes a thorough assessment of need and writes a detailed plan about how the care should be delivered. This plan takes into account the persons wishes and their particular likes and dislikes. Wherever possible service users and their families are consulted on issues regarding the home and their care arrangements. There are a range of signs and symbols around the house to assist service users to use the facilities as independently as possible. During their stay service users can partake in a range of leisure activities inside and outside the home. Health and personal care needs are met, and the privacy and dignity of service users is respected. There is a consistent staff team who have a good understanding of service users needs. The staff treat the service users with dignity and respect whilst providing a lively and fun environment appropriate to the needs of young adults. Staff feel valued and well supported by the their colleagues and management. The organisation has a good staff- training programme in place. Feedback from carers of people using Colwill Lodge included; ‘ All the staff is wonderful’ ‘ Colwill is a excellent care home…have no complaints… a very happy parent knowing my daughter is kept safe and well’. Colwill Lodge DS0000031052.V311603.R02.S.doc Version 5.2 Page 7 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 Colwill Lodge DS0000031052.V311603.R02.S.doc Version 5.2 Page 8 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Colwill Lodge DS0000031052.V311603.R02.S.doc Version 5.2 Page 9 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 Colwill Lodge DS0000031052.V311603.R02.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. 1,2,3,4,5. This judgement has been made using available evidence including a visit to this service. The home provides prospective service users and their representatives with sufficient information for them to make an informed choice about whether or not to stay at Colwill Lodge for respite. The admissions process ensures that the service has adequate information to decide whether or not they can meet an individuals’ assessed needs. EVIDENCE: The home had a statement of purpose and service user guide, which described the environment and services available. A range of communication aids including signs, symbols and photographs are used to give any new residents information about the home and the support they could expect to receive. The management were in the process of updating information about the home to ensure that it can be accessed and understood by all people who use the service. The duty manager said that any changes to this information would be taken to a monthly service user meeting for their involvement and approval. Colwill Lodge DS0000031052.V311603.R02.S.doc Version 5.2 Page 11 The homes Statement of purpose says that Colwill Lodge provides short breaks/respite services to people with severe learning disabilities and additional special care needs on a planned and emergency basis. Referrals are mainly received from Social Services and many people have been using the service for several years. The inspector looked at records to establish the quality of the homes admissions procedure and spoke to one service user who was staying at Colwill for the first time. Following referral a thorough pre-admission assessment had been completed by the home to confirm whether or not the individuals needs could be met. If Colwill can meet the needs of the service user a transitional period is recommended. An introductory visit, followed by tea visits and then an over night stay is then arranged. People using the service for the first time were spoken to and said that they had been able to visit prior to their stay and were made to feel welcome by all the staff. Feedback from the specialist learning disability service confirmed that the home gathers sufficient information at the point of referral to ensure that all identified needs can be met during the individuals respite stay. The home has written procedures to manage emergency admissions. A representative from the Plymouth Social Services Learning Disability Team said that ‘ Colwill always responds to an emergency referral in a helpful and professional way’. The duty manager said that Local Authority contracts are provided detailing terms and conditions and fees. However, copies of these were not available on service user files. Colwill Lodge DS0000031052.V311603.R02.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. 6,7,8,9,10. This judgement has been made using available evidence including a visit to this service. The home has a clear, consistent care planning process, which provides staff with the information they need to satisfactorily meet service users needs. Staff have a good understanding of how service users communicate and use this knowledge to encourage them to make choices and have control where possible about their care and lifestyle during their stay at Colwill Lodge. EVIDENCE: The care plans and records relating to four service users residents were looked at in detail during the inspection. These records included good information about each individuals needs. Each area of care was supported by a detailed assessment, behaviour management guidelines, risk assessments and information about any involvement from other agencies. Colwill Lodge DS0000031052.V311603.R02.S.doc Version 5.2 Page 13 The detail of the information was dependent on the complexity of the individuals needs. For one service user with profound physical disabilities the information available to staff was detailed and clear. The individuals’ morning, evening and nighttime routines were documented with step-bystep guidelines about how the care should be delivered. Agency and new staff said that the information about each service user is accessible to them and written in a way that they can understand. Care plans included detailed information about how each resident communicates. Although many of the service users have limited verbal communication, it was observed during the inspection that staff communicated with them sensitively and appropriately using verbal gestures and knowledge of individual ways of communicating needs. Signs, symbols and photographs were available around the home to assist people to use the facilities more independently. These included photos on bedroom doors, symbols/ pictures on toilet, bathroom and kitchen doors. Service users are encouraged and supported to partake in all aspects of life in the home. The acting manager said that the level of participation is dependent on the each individuals ability, although the home continues to explore ways of involving everyone. Examples of this were a monthly service user meeting where matters concerning the home are discussed, and a review of the information available to people using the service to ensure that it is provided in an appropriate format. Risk assessments had been written for all activities inside and outside the home. These confirmed that service users are supported to take responsible risks that had been assessed, and risk management strategies were in place. All records inspected were found to be well maintained, up to date and stored safely. Colwill Lodge DS0000031052.V311603.R02.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. 11,12,13,14,15,16,17. This judgement has been made using available evidence including a visit to this service. Service users are encouraged and supported to maintain their skills and enjoy leisure opportunities during their stay at Colwill Lodge. Service users are treated respectfully and are able to enjoy a selection of nutritious meals that meet their specific dietary needs. EVIDENCE: As part of the homes admissions procedure information is documented about an individuals skills, their likes and dislikes and particular interests. The manager said that whenever possible service users are encouraged to maintain their skills during their stay and also have the opportunity to partake in a number of leisure activities inside and outside the home. Colwill Lodge DS0000031052.V311603.R02.S.doc Version 5.2 Page 15 Information in records confirmed that service users are enabled to access community facilities as much as possible, such as local shops, pubs, clubs and churches. Day care is generally not provided at Colwill Lodge so most of the activities are planned during the evening and weekends. The home has the use of a minibus during this time. On the second day of the inspection some of the service users had chosen to go with staff to a local super store to shop for personal items and ‘treats’ for their stay at Colwill. Care records confirmed that where possible service users would be supported to attend any pre-arranged activities. The home has a large TV in the main sitting room and service users are able to have a television in their bedroom if they request. The home also has a sensory room for service users who specifically require this facility or for those who may need some private, quiet space. A range of craft equipment and games were also available. Service users spoken to said that they looked forward to going out on trips and were sometimes able to choose where to go. The minutes from a recent service user meeting were available, which confirmed that service users are asked to consider options for activities and to give their views about the facilities in the home. A monthly newsletter was also available, which included information about trips and events that service users had enjoyed. Discussion with carers confirmed that the home makes every effort to liaise with family and other significant people and consider this contact an important part of making the individuals stay as successful as possible. The parent of one service user said ‘ Colwill always keep me well informed of any issues concerning the home or the care of my daughter’ Information about service users dietary needs were recorded. Information was also available to care staff and the cook about where and when service users prefer to eat and any specialist equipment required. The mealtime was observed to be an unhurried relaxed occasion, with good quality food and special diets catered for. Staff assisted service users to eat in a dignified and helpful manner. Colwill Lodge DS0000031052.V311603.R02.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. 18,19,20. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: Service user files contained detailed information about each individual’s personal and healthcare needs. This information was written in a sensitive and respectful manner with consideration given to personal preference about how the care is delivered. Individual moving and handling guidelines were available and staff spoken to said that this information was crucial to ensure that care is delivered in a safe and consistent way. Colwill Lodge DS0000031052.V311603.R02.S.doc Version 5.2 Page 17 As service users are only staying at Colwill for a short time they retain their own GP but the home has arrangements with a local surgery for advice or an emergency situation. Information is recorded at the point of admission about all other agencies involved in the individuals care. Service users are supported to attend any prearranged appointments and the home regularly liaises with a range of health professionals for advice and support relating to the home and individual needs. A representative from the Learning Disability service said ‘ Colwill provides a excellent standard of care, and has provided 1st class support to one service user who had recently been in hospital’ Throughout the inspection staff were observed supporting service users sensitively and respectfully with their personal and healthcare needs. The inspector praised the staff team for their gentle and reassuring approach to service users who were feeling unwell or distressed. The inspector was able to observe a staff handover meeting where staff were given clear information about the people using the service that evening and any important changes to their health or care arrangements. The duty manager described the homes medication procedures and a sample of records were inspected. These were found to be clearly recorded and up to date. As the home only provides respite, the procedure is that all medication is checked in and out of the home for each person on each visit. No medication is retained in the home when a service user is not in residence. Discussion took place with the acting manager for the need to ensure that any service user who is able to self medicate is provided with appropriate storage facilities during their stay. Records confirmed that despite recent review of the homes medication policies and procedures some minor errors have still occurred. The manager said that the changes in procedures do ensure that these errors are recognised and dealt with promptly. The manager confirmed that staff receive medication training from the homes pharmacist and community nursing services when required. Colwill Lodge DS0000031052.V311603.R02.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems in the home ensure that all service users are listened to and any concerns or complaints are dealt with promptly and appropriately. Adult protection procedures ensure that service users are protected from abuse, neglect and self-harm. EVIDENCE: The information provided by the Registered Manager prior to the inspection confirmed that the home had not received any complaints during the last 12 months. The Commission for Social Care Inspection had not received any complaints about this service since the last visit. Colwill Lodge follows the Plymouth City Council Corporate Complaints procedure, which is available to service users and visitors in the main reception area. This information is also available to service users in a pictorial/symbol format. Records and discussions with staff confirmed that the homes daily recording procedures, hand over, staff and service user meetings are all used to check that individuals are happy with the care they are receiving. This daily Colwill Lodge DS0000031052.V311603.R02.S.doc Version 5.2 Page 19 monitoring ensures that any matters can be addressed promptly and that all service users are listened to. The home has comprehensive corporate policies regarding adult protection, whistle blowing, gifts and legacies. Training material confirmed that staff receive information about all issues relating to abuse and how to ensure the safety of service users. Some of the records inspected contained guidelines for staff to support service users who may present difficult and challenging behaviour. The manager said that when necessary the home would work closely with the specialist learning disability challenging behaviour services to review the care arrangements and to ensure that staff understand and follow the agreed guidelines. Service users personal money is only held in the home during their stay. A record is kept of any money spent and a facility provided to keep each individuals money safe. Information about arrangements for money and any support required is not recorded as part of the service user care plan. Colwill Lodge DS0000031052.V311603.R02.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. 24,25,26,27,28,29,30. This judgement has been made using available evidence including a visit to this service. Colwill Lodge is decorated and furnished to a generally good standard. The physical design and layout of the home enables service users to stay in a safe, well-maintained and comfortable environment, which encourages independence and meets their needs. EVIDENCE: The homes Statement of Purpose says that ‘ Colwill Lodge provides a full range of facilities and services to meet the needs of service users’ The inspector was able to complete a full tour of the premises and all parts of the home were found to be clean and well maintained. Colwill Lodge DS0000031052.V311603.R02.S.doc Version 5.2 Page 21 The property is a large detached bungalow with level access and rooms all on one floor. The service is therefore able to accommodate people with more complex and physical care needs. Service users have access to a large communal sitting room and separate dining area. There is also a sensory room and large enclosed garden. There is a large main entrance area with automatic doors for people who may use a wheelchair or have other mobility difficulties. A range of information about the service is available in this area for service users and visitors. There is sufficient office and storage space for the completion of administrative tasks and the safe storage of records. Service user bedrooms were found to be clean and tidy. All bedrooms have locks and a facility to store personal items. Equipment in bedrooms is provided dependent on each individuals needs. This information is documented and available to the staff preparing the rooms. A photograph of the service user is put on the bedroom door at the start of their stay to make them feel welcome and to enable them to recognise their room. Whenever possible service users are able to choose the room that they stay in. Two bedrooms and one bathroom have recently had ceiling track hoists fitted to meet the care needs of service users who regularly use these rooms. The home has a detailed maintenance and renewal programme and the inspector was shown some of the bedrooms that had been decorated since the last inspection. It was noted that some of the bedroom carpets need renewing and the overall impression of the communal hallway leading to the bedrooms would be improved if the paint- work on the skirting boards were repaired. Although bedrooms do not have en-suite facilities there are a sufficient number of bathrooms and toilets, which are located close to all the individual and communal rooms. The home has a range of specialist equipment to meet the care needs of service users. These include, grab rails, mobile hoists, ceiling track hoists, shower/ toilet seats, ramps, call alarm system and a sensory room. Records confirmed that the home regularly liaises with the specialist Occupational and Physiotherapy department regarding the use of this equipment. Colwill Lodge DS0000031052.V311603.R02.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. 32,33,34,35,36. This judgement has been made using available evidence including a visit to this service. Service users’ needs are met by a sufficient number of competent, well-trained and motivated staff. EVIDENCE: Staffing rotas were available, which confirmed that sufficient numbers of staff were available to meet the assessed needs of the service users. Staffing levels are planned dependent on the number of people staying for respite and the levels of care required. Throughout the inspection staff were observed responding sensitively and respectfully to service users requests, and were able to use their knowledge of each individual to encourage choice and independence whenever possible. Colwill Lodge DS0000031052.V311603.R02.S.doc Version 5.2 Page 23 Staff were friendly and good-natured. They interacted with service users and as well as being courteous and respectful were also humorous and fun, which people clearly enjoyed. There is a generally consistent staff team and those spoken to had a good knowledge of the people who frequently use the service. Agency staff spoken to said ‘ Colwill Lodge is a good place to work’, they also said that they feel well supported and are not asked to do anything they don’t understand or have information about. Feedback from staff spoken to during the inspection included; ‘ Colwill is a lovely place to work’ ‘ There is a good mix of skills in the staff team’ Feedback received from staff questionnaires included; ‘ There is good communication between staff and carers’ ‘Very good, supportive team work’. One service user said that the staff were kind and caring and would deal with any problems. A thorough training programme is in place to ensure that service users’ needs are fully met by skilled staff. Records confirmed that all staff undertake regular health and safety training as well as a range of specialised training courses relevant to service users needs. A sample of staff records were seen and confirmed that the homes recruitment procedure is robust and ensures the protection of people using the service. In addition to the Registered Manager each team of staff are supported by a duty manager and a thorough hand over meeting takes place at the end of each shift. There are regular team meetings and staff also receive 1:1 supervision every 6-8 weeks. Colwill Lodge DS0000031052.V311603.R02.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. 37,38,39,41,42. This judgement has been made using available evidence including a visit to this service. The management approach is open and inclusive, providing clear leadership and guidance. Service users rights, health, safety and welfare are protected and promoted. EVIDENCE: The Registered Manager for Colwill Lodge has approximately 12 years experience of management. He holds a National Vocational qualification in care, the D32/33 assessor award and also completed the Registered Managers award in June 2004. Colwill Lodge DS0000031052.V311603.R02.S.doc Version 5.2 Page 25 In addition to the Registered manager three assistant managers also support the staff team. Staff spoken to said that there is always a senior member of staff on duty to answer any questions and provide support. All staff spoken to were aware of their roles and had a good understanding of the needs of the service users. Staff said they felt well supported by management and other members of the team. Service users, carers, relatives and staff are encouraged to voice any ideas or issues informally or through supervision and meetings. Minutes were available from meeting to confirm that service users are kept informed and asked their views about issues relating to the home and their care. Carers are invited to attend a regular bimonthly meeting to meet with staff, discuss any issues and listen to a speaker about current related topics. One carer said that this was a very valuable time and allows carers a social opportunity to be involved in the home and matters concerning their relative’s care. The home gathers feedback from service users, carers and other agencies as part of their on-going quality assurance process. The manager said that the home is in the process of reviewing all questionnaires to ensure that they can be understood and used by all people receiving a service. All records inspected were found to be well maintained and up to date. Records were organised in a way that made it easy for the inspector to get a picture of the individuals needs, and to understand how their needs were being met by the home and other agencies. Health and safety continues to be a priority in the home, and health and safety practices described and observed were found to be satisfactory. All accidents and incidents had been reported and documented. Detailed risk assessments had been carried out for all safe working practices. Colwill Lodge DS0000031052.V311603.R02.S.doc Version 5.2 Page 26 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 3 2 3 3 3 4 4 5 3 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 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 X 3 3 X Colwill Lodge DS0000031052.V311603.R02.S.doc Version 5.2 Page 27 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. 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. 2. 3. Refer to Standard YA20 YA23 YA24 Good Practice Recommendations The Registered Provider should continue to monitor and review the procedures for the dispensing of medication to ensure that as far as possible errors do not occur. Information about arrangements to support service users with their money during their stay should be recorded as part of the care plan process. To improve the general impression of the home, the manager should consider some redecoration to the communal hallway leading to service user bedrooms and renewal of some carpets as discussed during the inspection. Colwill Lodge DS0000031052.V311603.R02.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Colwill Lodge DS0000031052.V311603.R02.S.doc Version 5.2 Page 29 - 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!