Inspection on 25/11/05 for Crest Lodge

This inspection was carried out on 25th 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 but made no statutory requirements on the home.

Other inspections for this house

Crest Lodge 15/01/09

Crest Lodge 16/01/07

Crest Lodge 05/07/05

Crest Lodge 17/01/05

Crest Lodge 11/08/04

Crest Lodge 16/02/04

Similar services:

1 Marten Road

Daubeney House

Three Gables

Aldwick House

Prinsted

49 Glendale

The Springs Community

Crossways Community

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

CARE HOME ADULTS 18-65 Crest Lodge Churt Road Hindhead Surrey GU26 6PS Lead Inspector Marianne Barham Unannounced Inspection 09:20 25 November 2005 th Crest Lodge DS0000017604.V261388.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 Crest Lodge DS0000017604.V261388.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. Crest Lodge DS0000017604.V261388.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Crest Lodge Address Churt Road Hindhead Surrey GU26 6PS 01428 685327 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) Mr L Hasham Mr Thomas Feury Care Home 27 Category(ies) of Past or present alcohol dependence (6), Past or registration, with number present drug dependence (4), Mental disorder, of places excluding learning disability or dementia (27) Crest Lodge DS0000017604.V261388.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Out of the total 27, one resident may be admitted from the age of 25 years. This person will be within the category (MD) mental Disorder Residents are to be aged between 30 and 65 years. Up to 6 may be in the catergory (A) and up to 4 may be in the category (D). 5th July 2005 Date of last inspection Brief Description of the Service: Crest Lodge is a large detached property located in Hindhead, close to the amenities of Beacon Hill. The home is owned by Care Homes of Distinction and provides accommodation and specialist nursing care to up to 27 adults with enduring mental health needs. The accommodation is arranged over two floors with the first floor being accessed by stairs or passenger lift. All bedrooms are single occupancy and all have en-suite facilities. There is a bathroom and separate shower room on the ground floor and a bathroom on the first floor. Communal facilities include a lounge, two dining rooms and a designated smoking room. The home has its own mini-bus to access the local and wider community and there is parking for several cars to the front of the property. A public bus stop is close by. There are gardens to the front and rear of the property, however they are not at present accessible to service users as neither are enclosed and they lead onto a busy main road. The home has strong links with the local community and the service users regularly take part in local events and activities. Crest Lodge DS0000017604.V261388.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out at 09.20am by Marianne Barham, lead inspector for the service. The inspection was undertaken over a period of four hours and fifty minutes and was the second inspection in the Commission for Social Care Inspection (CSCI) year April 2005 to March 2006. The registered manager Mr Tom Feury was present and a total of eight service users and four members of staff were spoken with during this inspection. Records relating to the care of service users and management of the home were also examined as part of this inspection. What the service does well: What has improved since the last inspection? The rubbish has been cleared from the rear garden and the area has been made more accessible to the service users. Crest Lodge DS0000017604.V261388.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Crest Lodge DS0000017604.V261388.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Crest Lodge DS0000017604.V261388.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): N/A These standards were not assessed at this inspection. Please see report dated 5th July 2005 for detail on these standards. EVIDENCE: Crest Lodge DS0000017604.V261388.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 The home encourages and supports service users to make decisions about their lives. EVIDENCE: Service users are encouraged to make decisions and choices on a daily basis regarding their activities and meals. They are fully involved in the decorating and furnishing of their rooms, organising outings and holidays and the planning of menus. All service users manage their own finances, the home has a safe that they can keep money in if they wish, and this is managed by robust accounting procedures. The home holds service user meetings every two weeks and these are recorded with actions from previous meetings agreed. Service users spoken with confirmed that they are supported to make decisions about their lives. Crest Lodge DS0000017604.V261388.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 and 16 Service users take part in appropriate activities, they are part of the local community and their rights and responsibilities are recognised in their everyday lives. EVIDENCE: The home has a full programme of activities in place including educational and work based activities. Service users spoken with said that they were able to take part in a wide range of activities and that they felt supported by the staff team to do so. Several said that they enjoyed making use of the amenities in the local area and were welcome in the local community. The home actively encourages service users to gain employment if this is their wish. The service users choose their own level of activities, and are supported by the staff team as necessary. The home has good links with the citizens Advice Bureau, which can be accessed at the ‘MIND’ day centre, and the local Post Office, which have been very helpful in assisting the service users in the change from benefit books to direct payments. Crest Lodge DS0000017604.V261388.R01.S.doc Version 5.0 Page 11 The home has strong links with local community, including the local school, post office and churches. The manager reported a good relationship with the neighbouring community, with service users welcome at any local events. Staff members support service users to participate in the civic process if they wish to do so. Service users have keys to their own rooms and are able to lock them if they wish. Members of staff knock on doors prior to entry. Risk assessments are carried out to determine the safety of service users having a key to the main door of the home, and some service users are able to have one and are free to come and go as long as they inform the staff. Service users are able to make themselves drinks and snacks, with staff support if needed. The inspector observed staff interacting with the service users in a meaningful and respectful way. Service users post is given to them unopened. Crest Lodge DS0000017604.V261388.R01.S.doc Version 5.0 Page 12 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 Service users are protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: The home has a policy and procedure in place for dealing with medicines and all staff are made aware of this and sign to show it has been read. Medication administration records were examined. These were completed accurately with no gaps or errors apparent. The medication is administered by, registered nurses who undertake regular medication update training. Medication is supplied mainly in blister packs from a local pharmacy. The pharmacy carries out audits and gives advice and training sessions to the home. The medication is stored securely and appropriately and record is kept of all medication received or returned to the pharmacy. No service users selfmedicate at present. Crest Lodge DS0000017604.V261388.R01.S.doc Version 5.0 Page 13 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): 22 Service users’ views are listened to and acted upon by the home. EVIDENCE: The home has a complaints procedure in place, which is available to all service users and their families. This is also contained in the service users guide. Service users spoken with know how to make a complaint if they need to. A service users meeting is held every two weeks, which the manager attends, and many minor issues are addressed at this. Minutes are recorded of these meetings and are made available to the service users. One complaint has been received since the last inspection, the home was asked to investigate by the local Social Services Team (SST) and no further action is to be taken. The inspector has asked that the home contact the SST to ask them to put in writing to the Commission that the matter has been concluded. Crest Lodge DS0000017604.V261388.R01.S.doc Version 5.0 Page 14 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): 28 The communal areas inside the home are sufficient to the needs of the service users, however the gardens are not suitable as they lead onto a busy main road and are not enclosed. EVIDENCE: A requirement was made at the last inspection on 5th July 2005 for the rubbish in the rear garden to be cleared and the area enclosed and made accessible so that the service users could have a safe area to sit or wander outside of the home. It is pleasing to see that the rubbish has been cleared and that the area has been made accessible, however it is not yet enclosed therefore the requirement is carried forward. Crest Lodge DS0000017604.V261388.R01.S.doc Version 5.0 Page 15 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): 35 The service users’ needs are met by, an appropriately trained staff team. EVIDENCE: The home has access to the organisation’s training coordinator who is responsible for devising and implementing the planned programme of training for all staff members. A formal induction process is in place and training needs are identified from this and through the appraisal process. All members of staff have individual training records maintained with copies of training certificates held on file. The home provides a good range of training that includes developmental courses as well as the mandatory training. Members of staff spoken with said that they attended training courses frequently and felt that they received enough support and training to carry out their jobs well. Crest Lodge DS0000017604.V261388.R01.S.doc Version 5.0 Page 16 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): 42 The health, safety and welfare of service users is promoted and protected by the home. EVIDENCE: All members of staff receive health and safety training at induction, with refresher training on an annual basis. The home has a health and safety policy and members of staff are made aware of this through supervision, meetings and training sessions. There is a First Aid trained member of staff on every shift. The home has an ongoing programme of staff training for all health and safety related issues such as fire safety, COSHH, moving and handling and infection control. Health and safety audits are completed regularly with actions taken recorded. A full fire evacuation drill is carried out and recorded weekly to ensure the procedure remains fresh in the service users’ minds. Crest Lodge DS0000017604.V261388.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X 3 X X X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X 2 X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X X X X 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Crest Lodge Score X X 3 X Standard No 37 38 39 40 41 42 43 Score X X X X X 3 X DS0000017604.V261388.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? YES 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 28 Regulation 23 (2) (o) Requirement A safe, enclosed and accessible garden area must be provided for the use of the service users in the home. Timescale for action 25/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Crest Lodge DS0000017604.V261388.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Crest Lodge DS0000017604.V261388.R01.S.doc Version 5.0 Page 20 - 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. 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