Inspection on 06/11/06 for Cypress Lodge

This inspection was carried out on 6th November 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cypress Lodge 26/11/07

Cypress Lodge 23/02/06

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 Cypress Lodge Station Road Potter Heigham Norfolk NR29 5HX Lead Inspector Mrs Judith Huggins Unannounced Inspection 6th November 2006 03:15 Cypress Lodge DS0000063010.V319314.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Cypress Lodge DS0000063010.V319314.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Cypress Lodge DS0000063010.V319314.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cypress Lodge Address Station Road Potter Heigham Norfolk NR29 5HX 01263 722469 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) janithhomes.com@btinternet.com www.janithhomes.org Janith Homes Limited Mrs Jane Alison Pearse Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Cypress Lodge DS0000063010.V319314.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd February 2006 Brief Description of the Service: Cypress Lodge is an attractive and spacious home standing near to the centre of the village of Potter Heigham. It currently offers care to four service users with a learning disability, and is registered for six. There is a good range of communal space and attractive gardens. All bedrooms are en-suite. The service is owned by Janith homes an established provider, which has four other homes in the area. Inspection reports are available but would need to be explained to residents. The company’s website (www.janithhomes.org) says that inspection reports are available on request. Residents’ relatives say that they know how to access inspection reports. Fees for the service range from £680 to £1167 per week according to need. There are additional charges for transport to requested activities (but not for health care appointments), hairdressing, dry cleaning, outings and holidays and personal spending. Cypress Lodge DS0000063010.V319314.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The staff at the home were told the inspector would be coming, a few days before she visited. This is so she could be sure there would be someone at home, and that the manager would be there to help with some of the information. The visit to the home lasted about four and a half hours. The inspector talked with all of the residents, the staff member on duty, and the manager. She also looked at some parts of the home, including four bedrooms. She found out other things about the home from people’s care plans and other records. What the service does well: What has improved since the last inspection? Another bedroom with its own shower and toilet has been made for two people who want to share. Cypress Lodge DS0000063010.V319314.R01.S.doc Version 5.2 Page 6 The manager has started the training she needs to keep her up to date and help with the way she runs the home. 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. The summary of this inspection report can be made available in other formats on request. Cypress Lodge DS0000063010.V319314.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cypress Lodge DS0000063010.V319314.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager needs to make sure that she has full assessment information for prospective residents - consistent with a good admissions policy. Quality would have been good in this area had the full information been available. EVIDENCE: There are currently two vacancies and one person has been referred from another home in the same group. The manager has no complete assessment available to her on the premises but says clearly the person is known to her and the organisation. A requirement has been made. Cypress Lodge DS0000063010.V319314.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The outcome will be good with increased frequency of review of each separate goal to identify progress, and improved linking together of goals and risk assessments. EVIDENCE: The personal goals of residents are set out. Residents spoken to say that staff talk to them about what they want to do. Visiting relatives completing comment cards say that they are kept informed of important matters and - if people are unable to make decisions - that they are consulted about their care. One file contained a strategy for managing a behaviour which the manager says is no longer in use. In order to avoid confusion the care plan documentation needs to be revised so show this is no longer considered appropriate or necessary and so that the plan reflects the current needs of the person concerned. A requirement has been made. Cypress Lodge DS0000063010.V319314.R01.S.doc Version 5.2 Page 10 The goals for each person are recorded on a single sheet. Comments on in house review notes on the files seen predominantly show no change. The review frequency has slipped. A recommendation has been made. Risk assessments are in place but are not consistently cross referenced with progress towards goals. A recommendation has been made. A relatives comment card indicates that staff are responsive and creative in responding to a residents needs. Cypress Lodge DS0000063010.V319314.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a variety of formal and informal activities, inside and outside the home. They are able to maintain relationships with friends and family, participate in daily routines and enjoy their meals and mealtimes. EVIDENCE: Residents confirm that there are lots of things to do. This includes some attendance at college, and day services, and progress is being made for one person to obtain some work experience. Residents use the local facilities based on records and discussion. Records show one persons interest in the garden has been encouraged and supported. During the visit, residents were encouraged to discuss a range of issues. this included, on arrival, discussing events in the news. Residents are supported with their individual interests and hobbies. Cypress Lodge DS0000063010.V319314.R01.S.doc Version 5.2 Page 12 Records, discussion and observation show residents are supported with personal relationships and maintain contact with their families. All three relatives completing comment cards say that they feel welcome in the home at any time. There is a cordless telephone so that residents can make or receive calls in private. Residents help with chores around the home, including keeping their rooms tidy. They say that staff knock on their doors before going in. They are able to have keys although none had their rooms locked when the inspector visited. After the evening meal, staff were heard discussing who was going to help with the cleaning up and getting volunteers for this. Residents say they are involved in choosing what they would like to eat and in planning menus. Observation shows they also help to shop for food if they wish. Residents who are able to read and write have been encouraged to write out the menus on behalf of the group and others are helped to refer to them. During the meal, the manager and staff member chatted with residents, encouraging appropriate social skills - although this was on one occasion rather parental in approach. This could be due to some hearing impairment in residents based on observation and file notes. Cypress Lodge DS0000063010.V319314.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The outcome would be good had the errors of dating on medication administration records been identified, so showing improved rigour in ensuring the safekeeping and safe administration of medicines. Residents receive personal support in the way they need and their health needs are met. EVIDENCE: The pre-inspection questionnaire shows that none of the residents needs help with personal care, washing and dressing. Residents say that they see their doctor and dentist. This is supported by records. These also confirm a range of other health checks and screening. There is instruction in one care plan that blood sugar is to be monitored daily. The manager says that this is no longer necessary, but the care plan has not been revised to take this into account in providing clear and current guidance to staff. (Given the support identified is in excess of that now required and that staff have a good understanding of residents needs, the impact of this on the outcome and welfare of the individual concerned is minimal.) This is linked to requirement under section 2. Cypress Lodge DS0000063010.V319314.R01.S.doc Version 5.2 Page 14 Medication is stored in a locked cupboard in the small office, which was also locked on arrival for the fieldwork visit. It is administered from monitored dosage packs. However, the medication administration record for one person is inaccurate in its start dates and therefore in the dates upon which staff have administered medication. This means the statutory record is inadequate. A requirement has been made. There are significant stocks of equipment for checking blood sugar that the manager says is no longer necessary. This needs returning to the pharmacy. Cypress Lodge DS0000063010.V319314.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents know their concerns will be taken seriously and that they are protected and safe from abuse. EVIDENCE: Residents say they know who to speak to if they have concerns, and name the manager and staff as being those they should approach. They say staff are good and that none of them are unpleasant to residents. Two out of three relatives completing comment cards say that they know what the complaints procedure is. Residents feel safe in the home. Discussion with the staff member on duty shows a basic awareness of conduct that would be seen as abusive. All residents are able to communicate to some extent and indicate whether they were not happy about the way they were being cared for. None spoken to had any concerns or complaints they wished to raise with the inspector. Their interactions with the staff member and manager were relaxed and comfortable. Cypress Lodge DS0000063010.V319314.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a homely and safe environment that is clean and hygienic. EVIDENCE: The home is well maintained and furnished in a homely and domestic manner. There is no need for additional adaptations at present but access arrangements and an emergency call system for the shared room at the rear of the home will need review if occupancy increases. None of the current residents requires assistance with mobility and do not require assistance to use the stairs. At present, one person has temporarily removed rooms because of a failure of heating to the usual room. The manager has made arrangements for repair so no requirement is made. Areas of the home seen were clean. There is one area with a slight odour associated with continence difficulties which may indicate the need for enzyme cleaners or more extensive work. A recommendation has been made. Cypress Lodge DS0000063010.V319314.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is room for improvement in staff obtaining qualifications, and in notes kept of anomalies or gaps in employment records. Evidence of supervision also needs to be improved. The residents are supported by an effective staff team. EVIDENCE: None of the care staff has NVQ 2 qualifications. A requirement has been made. The staff member spoken to confirms good access to policy guidance to support the tasks they need to undertake and has a good understanding of the needs of residents. However, there is evidence in records that challenging behaviour occurs from time to time, or that there is a risk of this. A recommendation has been made. Cypress Lodge DS0000063010.V319314.R01.S.doc Version 5.2 Page 18 There are some occasions then the choices of residents are limited because there is only one member of staff on duty. The manager says that she is attempting to recruit a part time member of staff who can provide additional cover at weekends or during holiday periods. This would be welcome in increasing opportunities available to residents. (Should the remaining two vacancies be filled the Commission would be looking for staffing levels, especially at weekends, to be increased.) The manager has attended training in staff recruitment and selection. The organisation has been revising paperwork so that the application form provides for a full employment history for staff now being recruited. An existing staff file shows an unexplained gap and anomalies in dates on two different pieces of documentation. A requirement has been made. The staff member on duty confirms induction and the manager says LDAF standards are used. She was advised to research this further as recent information indicates these are not wholly cross referenced with Common Induction Standards. A recommendation has been made. The manager manager meets with staff regularly on an informal basis, and has carried out some staff supervision. However, the last recorded session for one person was in July, and although the manager says there has been another, there are no records. There is a lack of evidence to show it happens with the nature and frequency set out in standards. The recommendation made at the last inspection has not been fully implemented. A requirement has been made. Cypress Lodge DS0000063010.V319314.R01.S.doc Version 5.2 Page 19 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): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a well run home - the manager is working towards her management qualification. There are systems to take into account the views of residents when looking at the quality of the service. The health, safety and welfare of residents is promoted and upheld. EVIDENCE: The manager is registered and appropriately experienced. She has a qualification in care and is currently pursuing NVQ 4 training and has participated in the organisations management development programme (certificate seen). Cypress Lodge DS0000063010.V319314.R01.S.doc Version 5.2 Page 20 The manager carries out regular monitoring of service quality and, arising from this, identifies areas in which improvements can be made. Residents say that they discuss what is good and what can be improved. There are monitoring visits on behalf of the providers although these do not wholly meet regulations. A requirement has been made. A sample of records associated with safety of the home were checked. These show testing and servicing of appliances and regular fire drill practices. There is a fire risk assessment. The fire detection system was serviced in September. The fire officer has suggested that three monthly testing needs to be arranged for emergency lighting systems and although these are serviced, the three monthly tests have not yet been arranged. A recommendation has been made. There are assessments for the use of cleaning chemicals although these are not all dated. The stock of cleaning material is held in the office - locked when not in use. Cypress Lodge DS0000063010.V319314.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X Cypress Lodge DS0000063010.V319314.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? NO 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 YA2 Regulation 14 Requirement The registered persons must ensure complete information is obtained and available about prospective residents, so that the ability of the service to meet needs can be better assessed and demonstrated before the person starts being introduced to the service. The registered persons must make sure care set out in care plans is that required to meet the current health and welfare needs of the service user concerned. The registered persons must accurately record the dates on which medication is administered to service users. The registered persons must arrange for a minimum of 50 of care staff to start NVQ training. The registered persons must ensure there is written explanation of gaps in employment history as per revised regulations, and must ensure anomalies are explored with applicants. DS0000063010.V319314.R01.S.doc Timescale for action 31/12/06 2. YA6 YA19 15 31/01/07 3. YA20 13 & 17.1 Sch 3 18.1 31/12/06 4. YA32 31/03/07 5. YA34 13.6 19 Sch 2 31/12/06 Cypress Lodge Version 5.2 Page 23 6. YA36 18.2 7. YA39 26 The registered persons must provide adequate supervision for staff. For the purposes of this regulation, it needs to be with the agenda and frequency set out in national minimum standards. The registered persons must provide reports of visits made on behalf of the registered providers. The visits must be carried out in accordance with the regulation. 31/01/07 31/01/07 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 YA6 YA6 YA9 Good Practice Recommendations The registered persons should make sure that reviews of all care plans and individuals’ risk assessments take place at least every six months. The registered persons should document individuals’ goals separately so that progress towards these can be broken down, identified and reviewed more effectively. The registered persons should ensure personal goals and risks are linked clearly to show whether the risk is unacceptable or whether residents can acquire additional skills to help minimise them and achieve their goals. The registered persons should take measures to deep/enzyme clean or replace the carpet in a rear hallway to remove odour. The registered persons should, following recent changes in the staff team, undertake an evaluation of training needs for the staff team, linked to the specific needs of residents. The registered persons should check whether LDAF standards have been appropriately revised to take into account the introduction of Common Induction Standards. The registered persons should discuss with the fire officer the process of testing the effectiveness of emergency lighting systems, to make sure that existing arrangements are adequate for the fire safety officer’s purpose and to meet their recommendations. DS0000063010.V319314.R01.S.doc Version 5.2 Page 24 4. 5. 6. 7. YA30 YA32 YA35 YA42 Cypress Lodge Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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. 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