Inspection on 08/11/05 for Conifer Lodge

This inspection was carried out on 8th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Conifer Lodge 22/09/08

Conifer Lodge 23/10/07

Conifer Lodge 06/06/06

Conifer Lodge 12/07/05

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Conifer Lodge 134 North Brink Wisbech Cambridgeshire PE13 1LL Lead Inspector Elaine Boismier Unannounced Inspection 8th November 2005 9:25 Conifer Lodge DS0000062547.V260419.R01.S.doc Version 5.0 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 Conifer Lodge DS0000062547.V260419.R01.S.doc Version 5.0 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. Conifer Lodge DS0000062547.V260419.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Conifer Lodge Address 134 North Brink Wisbech Cambridgeshire PE13 1LL 01945 474912 01945 583941 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) Ermine Care Ltd Ms Dianne Pauline Eaton Care Home 15 Category(ies) of Learning disability (15) registration, with number of places Conifer Lodge DS0000062547.V260419.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The maximum number of places not to exceed 15 at any one time Date of last inspection 12th July 2005 Brief Description of the Service: Conifer Lodge is an adapted two-storey domestic dwelling situated on the outskirts of the Cambridgeshire market town of Wisbech and is in walking distance from the town centre. Local amenities include shops, pubs and leisure facilities. The home provides accommodation care and support for a maximum number of 15 people, between 18 and 65 years of age, with a learning disability. All bedrooms have ensuite facilities and are for single occupancy. In addition to the ensuite facilities the home provides 3 toilets and has two bathrooms. There are two communal rooms and a large garden that provides space for games and gardening activities. Care Principles Ltd became the new owner of Ermine Care Ltd, the registered provider of Conifer Lodge, on 1st April 2005. Conifer Lodge DS0000062547.V260419.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The first inspection of the home was on 12th July 2005, after the home was first registered with the Commission for Social Care Inspection on 10th December 2004. This is the second statutory inspection of Conifer Lodge, Wisbech for 2005/6 that was carried out between 9:25 and 12:30 and took 3 hours to complete. On the day of this inspection there were 15 residents living at the home, of which 7 were spoken to. Also spoken to were staff, including the Registered Manager. Documentation was examined and a tour of the premises was made to complete the inspection process. It was pleasing to note that the home has made considerable progression in making Conifer Lodge more homely since the inspection of July 2005 and that the running of the home was in the best interests of residents. At the time of the inspection the home had a welcoming atmosphere. What the service does well: The home does well in a number of areas: • Residents are encouraged to engage in activities provided by local communities as well as the home. These activities include educational and leisure pursuits. Residents feel well supported by the home. One resident said that they enjoyed living at Conifer Lodge as the staff were well liked. Comments made by residents at a meeting included, “Finally the residents agreed that Conifer lodge was an OK sort of place really”. The home takes action in response to residents’ views as practicable as possible. • • • • What has improved since the last inspection? Following the last inspection of the home there were 6 requirements and 2 recommendations made as part of “good practice”. Five of the 6 requirements have been met; one recommendation has been fully considered. The remaining Conifer Lodge DS0000062547.V260419.R01.S.doc Version 5.0 Page 6 recommendation should be fully responded to before April 2006. Other improvements have also been made. The home is to be commended in making these improvements since the inspection of July 2005. These improvements are: • Examination of residents’ care files and discussion with a resident confirmed that the two requirements have been met with regards to the any limitations imposed on residents in accessing the kitchen area and having their lighters/matches kept overnight by staff. A requirement has been made that risk assessments of all residents were to be carried out should they access the kitchen area. Two residents’ care files seen included these risk assessments and this was confirmed by direct observation and discussion with the Registered Manager and staff of the home. As a result of this finding, this requirement has been met. A recommendation was made that residents should be consulted about their involvement with menu planning, including their preferred time when they wish to have their main meal. This recommendation has been considered. Changes to the menu are being made to include a wider variety of food and to exclude the least preferred menus, such as dishes made with lamb. The main meal is held in the evening. Residents are provided with a more “healthier” diet. Residents live in a more homely place. Replacement carpets and flooring have been provided in some areas of the home. Pictures and photographs (of residents’ trips out) are hanging on walls in communal areas. A requirement was made the room temperature where medication is kept must not exceed the optimum level. Action is being taken to ensure that the temperature of this room remains satisfactory for the safe storage of medication. As a result of this action this requirement has been met. A requirement was made for photographs of residents to be available. This requirement has been met. • • • • • • What they could do better: The home could improve in 3 noticeable areas: • The home should consider providing documentary evidence that residents have been actively consulted in drawing up their care plans. Conifer Lodge DS0000062547.V260419.R01.S.doc Version 5.0 Page 7 • A requirement was been made for full and satisfactory information about staff must be obtained and kept in the home. Two staff files were seen. One of these did not have a POVA check carried out on the member of staff before they started working at Conifer Lodge. As a result of this an immediate requirement was made. A recommendation was been made that the Registered Manager should successfully complete the Registered Manager’s Award by the end of 2005. Due to matters arising at the college the Manager stated that completion of the award has been delayed. A recommendation is that she should complete the award by 31st March 2006. • 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. Conifer Lodge DS0000062547.V260419.R01.S.doc Version 5.0 Page 8 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 Conifer Lodge DS0000062547.V260419.R01.S.doc Version 5.0 Page 9 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): EVIDENCE: None of these standards were assessed on this occasion. Conifer Lodge DS0000062547.V260419.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7, 8 & 9 Residents are well supported and are actively consulted about how they wish to live their lives although recording of this involvement could be improved upon. EVIDENCE: Examination of two residents’ care files was carried out. Care plans provided sufficient detail to give clear guidance for staff in how to meet the assessed needs of the residents. Staff considered that residents were included in the drawing up of the care plans although documentary evidence to support this consultation process was not available in the files that were examined. A recommendation has been made about this as part of good practice. During the last inspection it was noted residents do not have access to the kitchen area, as the door is kept locked by staff. Risk assessments of entry to the kitchen area, by all residents, were to be carried out by the home and any limitations agreed with the resident must be recorded. Examination of two residents’ care files were seen that included risk assessments for being in the kitchen. Discussion with staff, including the home Manager, and observation of Conifer Lodge DS0000062547.V260419.R01.S.doc Version 5.0 Page 11 the activity of a resident, confirmed that two requirements made following the last inspection have been met. Also during the last inspection it was reported that residents who choose to smoke were requested to give lighters/matches to staff at nighttime although there was no record seen as to how the home had consulted residents about this. A requirement was made as a result of this finding. Discussion with the Manager and a resident confirmed that residents’ have, where practicably possible, been consulted about the safeguarding of lighters/matches. Copies of minutes of two residents’ meetings were seen. Information provided suggested that residents are actively consulted about how they wish to live their lives and any changes they proposed about the running of the home. Residents’ positive comments were recorded about the inclusion of a kitchenette area for them to practice life skills in making drinks and meals for themselves. As a result of suggestions made by residents, at meetings held at the home, pictures and photographs have been provided on walls in communal areas and these were seen during the tour of the premises. Conifer Lodge DS0000062547.V260419.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 14, 15 & 17 Residents are well supported in personal development. EVIDENCE: Due to limitations of the kitchen area residents were not able to practice life skills that included meal preparation. Discussion with the Manager, staff and examination of the minutes of a residents’ meeting evidence suggests that action has been taken to introduce a kitchenette area to the home. At the time of the inspection it was noted residents were engaged in tasks such as making arrangements to go shopping; helping with drinks for other residents; washing up and placing recyclable rubbish in an appropriate receptacle. During the tour of the premises it was noted that walls in some of the communal areas had photographs of residents visiting Manchester United football club, walking in the countryside and taking part in horse riding. The residents’ survey indicated responding residents were 100 satisfied with the activities provided and 100 of the responding residents considered that staff supported them in the activities. According to the Manager those responding Conifer Lodge DS0000062547.V260419.R01.S.doc Version 5.0 Page 13 residents who stated, in the survey, that they would like to attend college, all are now attending further education on a full or part time basis. A resident reported that he enjoyed going to college. Information provided during discussions with a resident indicated that relationships with other residents of the home are forged and family contact is actively encouraged. A recommendation was made for residents to be active in menu planning or food preparation and to establish at what time they preferred to have their main meal. Discussion with staff, including the Manager and examination of a residents’ survey (50 of whom said the food was “horrible”) and examination of minutes of a residents’ meeting indicated that this recommendation has been considered to include a wider range of foods (such as lasagne, stroganoff and curries) and to exclude least liked foods such as dishes made with lamb. Staff confirmed that the main mealtime for residents is now in the evening time, rather than at lunchtime. According to staff, residents have been introduced to a “healthier” range of foods to include pastas, brown bread and fruit. Conifer Lodge DS0000062547.V260419.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 Systems are in place to ensure residents are protected from being given medication stored in an unsafe manner. EVIDENCE: A requirement was made for the temperature of the room where medication is stored not to exceed 25 degrees centigrade as room temperatures had been previously recorded to be 27-28 degrees centigrade on a number of occasions. Examination of records for temperatures of the room, where medication is stored, were seen for the months of September, October and up to 8th November 2005. On the whole the range of temperatures were within a safe range. The Manager reported that arrangements are in place to install equipment to maintain room temperatures for the safekeeping of medication. As a result of this action taken this requirement is considered to be met. Conifer Lodge DS0000062547.V260419.R01.S.doc Version 5.0 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): 23 Robust systems are in place to protect residents from abuse. EVIDENCE: The home has demonstrated robust reporting procedures, to include the local authorities, police and the Commission, following allegations of abuse against residents. Satisfactory action has been taken, by the home, in reducing the risk of further abuse to residents when such allegations have been made, whilst investigations have been carried out. Conifer Lodge DS0000062547.V260419.R01.S.doc Version 5.0 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 & 30 Residents live in a clean and homely place. EVIDENCE: Carpets have been replaced in some areas of the home and easily maintained floor covering has been provided in well-used areas of the home that include the dining and conservatory areas. Following suggestions made by residents, walls in communal areas were noted to have more pictures and there were photographs of residents visiting Manchester United football club and engaging in walking and horse riding activities. On the day of the inspection the home was clean and free of offensive odour. Conifer Lodge DS0000062547.V260419.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34 Although recruitment and vetting procedures have improved, residents remain at risk of harm. EVIDENCE: During examination of two staff files at the last inspection it was noted that there was no photograph on either file or recorded evidence that POVA checks had been made. In addition there was no proof of identity on one of the two files seen. During this inspection two staff files were examined and all information required was contained in one of the two files seen. The remaining file had all the required information except a POVA check had not been carried out before the member of staff commenced working at the home. As a result of this serious finding the requirement that was made has not been met. An immediate requirement has been made to protect residents from the risk of harm. Conifer Lodge DS0000062547.V260419.R01.S.doc Version 5.0 Page 18 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): 37,39 & 41 Residents live in a well managed home with their best interests placed first. EVIDENCE: At the last inspection of Conifer Lodge it was recommended that the Registered Manager should successfully complete the registered manager’s award by the end of December 2005. According to the Manager she has been unable to reach this target date due to changes in college tutors. Due to this delay the recommendation time scale for her to successfully complete the award has been extended to 31st March 2006. Since the last inspection of Conifer Lodge a residents’ survey has been carried out in the form of a questionnaire. Action has, or is being considered, in response to these results, as cited elsewhere in this report. Conifer Lodge DS0000062547.V260419.R01.S.doc Version 5.0 Page 19 During the last inspection only 2 of the 4 residents’ care files had photographs of the residents and none were available on other records seen. A requirement was made about this finding. Examination of the Client Quick Reference file was carried out and findings indicated that this requirement has been met. A requirement was made following the last inspection that photographs of all residents were to be kept in the home. Conifer Lodge DS0000062547.V260419.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 Score x 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 LIFESTYLES Standard No Score 11 3 12 4 13 x 14 4 15 3 16 x 17 Standard No 31 32 33 34 35 36 Score x x x 2 x x CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Conifer Lodge Score x x 3 N/A Standard No 37 38 39 40 41 42 43 Score 2 X 3 x 3 X x DS0000062547.V260419.R01.S.doc Version 5.0 Page 21 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA34 Regulation 17(2) & 19 Requirement The Registered Person must make sure full and satisfactory information in respect of care staff is obtained and kept in the home. The timescale for action to be taken by 01/09/05 has not been met. This requirement has been brought forward Timescale for action 08/11/05 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. Refer to Standard YA6 YA37 Good Practice Recommendations The Registered Person should consider ways to demonstrate that service users have been actively consulted in drawing up their care plans. The Registered Manager should successfully complete the Registered Managers Award by the end March 2006. Conifer Lodge DS0000062547.V260419.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB1 5XE 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 Conifer Lodge DS0000062547.V260419.R01.S.doc Version 5.0 Page 23 - 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!