Inspection on 15/08/05 for Dunheved Lodge

This inspection was carried out on 15th August 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 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

Dunheved Lodge 22/10/07

Dunheved Lodge 26/02/07

Dunheved Lodge 24/01/06

Dunheved Lodge 17/02/05

Dunheved Lodge 25/06/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Dunheve Lodge 9 Dunheved Road North Thornton Heath Croydon CR7 6AH Lead Inspector Barry Khabbazi Service User Inspection & Announced inspection. 15 & 16 August 2005 9:30am 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 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 Stationary 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. Dunheve Lodge G53 S25779 DunhevedLodge V190557 150805 stage4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Dunheved Lodge Address 9 Dunheved Road North, Thornton Heath, Croydon, Surrey, CR7 6AH Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8665 6405 020 8665 9034 Mr Cass Mohamedally Mrs Patricia Mohamedally Mr Eddy Muree Care Home 14 Category(ies) of Learning Disability (14) registration, with number of places Dunheve Lodge G53 S25779 DunhevedLodge V190557 150805 stage4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 17 February 2005 Brief Description of the Service: Dunheved Lodge is a registered care home for 14 adults with mild to moderate learning disabilities and medium overall care needs.Dunheved Lodge is one of three similar homes owned by Mr and Mrs Mohammedally.The detached property is keeping with the other houses on the road. There are 11 single bedrooms and two doubles. There is a communal through lounge, a dining room and a kitchen. Other facilities include a laundry, staff sleeping in room and staff office. The home is located in Thornton Heath, within easy access of public transport and local shops. Residents of the home attend day centres on weekdays and the home has its own minibus and car. There is an established rear garden with areas of lawn, mature trees and bushes, a patio area and a barbeque. The front of the premises has a slope for access, and an in-out drive. Dunheve Lodge G53 S25779 DunhevedLodge V190557 150805 stage4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection report refers to a pilot service user inspection on the 15/8/2005 and the inspector’s announced inspection of the 16/8/2005. This pilot is occurring in all three homes of a group owned by the service provider. The information gathered from the service users is recorded only in this summary below, but is referenced as supporting information throughout the report. The information from the lead inspector’s inspection is recorded throughout this report. The inspector was able to speak to all the residents on this occasion. During this inspection the manager was interviewed and records, care plans and the building were examined. The service users inspection process: Three service users volunteered to be involved in this pilot service user led inspection. A pictorial inspection guide was devised and training in the inspection process was provided to the three service users concerned. A more accessible form of feedback to the service users will also be devised following this report. The three service users that volunteered for this process spilt into two groups. Each group comprised of one or more of the inspecting service users, a support worker, or the lead inspector for the home. The inspecting service users then asked individual service users set questions covering a group of National Minimum Standards. This was supported by a pictorial question guide and the support worker and/or the inspector present. The main purpose of this pilot was to develop ways of involving the service users more. The information gathered from the service users was therefore seen as an additional bonus, and methods to improve the accuracy of responses will therefore need to be developed further. The conclusions below are based on verbal responses, pointing to pictures, and interpretation of facial expressions and body language and may therefore may not fully reflect all the views of the service users completely accurately. The service users’ inspection conclusions: 2 out of 12 service users chose not to be involved in the process. 8 0 1 3 out out out out of of of of 12 12 12 12 service service service service users users users users liked the home’s meetings. did not like the home’s meetings. liked the home’s meetings sometimes. did not fully respond to this question. 7 out of 12 service users liked the home’s activities. 0 out of 12 service users did not like the home’s activities. Dunheve Lodge G53 S25779 DunhevedLodge V190557 150805 stage4.doc Version 1.40 Page 6 5 out of 12 service users did not fully respond. {3 of these stated activities they enjoyed} Individual preferences of the home’s swings, parties, knitting and gardening were also made. Indications that cooking and writing were also enjoyed at the home’s day centre were made. 8 out of 12 service users liked the home’s outings. {1 of these said they were very good.} 0 out of 12 service users did not like the home’s outings. 4 out of 12 service users did not fully respond to this question. 3 service users also indicated that they were interested in going to the fun fair. Outings specifically identified as particularly enjoyed included: church, swimming, bowling, the park, trams, pic-nics and Barbeques. 8 out of 12 service users liked the home’s holidays. 0 out of 12 service users did not like the home’s holidays. 4 out of 12 service users did not fully respond to this question. Holidays specifically identified as particularly enjoyed included: Italy, Skegness and Butlins. 7 out of 12 service users liked the home’s food and also expressed their preferences. 0 out of 12 service users did not like the home’s food. 5 out of 12 service users did not fully respond to this question, but 3 of these did express preferences. 7 out of 12 service users liked their bedrooms. 1 out of 12 service users did not like their bedrooms. 4 out of 12 service users did not fully respond to this question. 8 out of 12 service users 0 out of 12 service users 4 out of 12 service users Preferences for watching said they liked the lounge. said they did not liked the lounge. did not fully respond to this question. the television and two for ‘James Bond’ films were made here. 8 out of 12 service users said they liked the home’s bathrooms. 0 out of 12 service users said that they did not like the home’s bathrooms. 4 out of 12 service users did not fully respond to this question. 7 1 0 4 out out out out of of of of 12 12 12 12 service service service service users users users users said the home was clean. said that the cleanness of the home was alright. did not think the home was clean. did not fully respond to this question. Two general questions were then asked and 5 service users answered this section. {a} What is good at this home ? Answers as follows: 1, Every thing, doing my laundry and ironing. 2, My own room, new friends, cooking. 3, The residents. 4, My room, outings. 5, Outings , the vegetable garden. {b} What is bad at the home ? Answers as follows: 1, No clear response. 2, Nothing bad, 3, None. 4, Nothing. 5, I don’t like peas. The three service users conducting the inspection then looked around the home with the inspector to identify areas of good practice. These were identified as follows: 1, The pictorial activities board is helpful and fun to make up. 2, Growing vegetables in the garden. 3, Having a room made for me and my husband. {bedroom and lounge} Dunheve Lodge G53 S25779 DunhevedLodge V190557 150805 stage4.doc Version 1.40 Page 7 The home’s feedback regarding the service users inspection pilot: 1, The service users enjoyed the process and most would like to do it again.. 2, Although the service users were used to being consulted by the home, they were not used to consulting each other. Now that the service users have had experience of consulting each other, the manager sees opportunities for developing this system further throughout the home. 3, The exercise inspired some service users to continue discussing preferences throughout the day. 4, It was a more relaxed atmosphere for all concerned than a traditional inspection. 5, The exercise promoted better communication between the inspector and the service users. The inspector got to know the service users and their individual speech patterns better and the service users became more familiar with the inspector. 6, The pictorial and text inspection guide should now be refined. Wording should be refined. One question/subject per page would be more effective. Some of the pictures should be changed and photos added, and a text only version would be better for those that can read effectively. 7, The manager and support workers think that it is a good idea to involve the service users more in the inspection and preferred this style of inspection. The inspectors conclusions regarding the service users inspection pilot: 1, The inspector agrees with the home’s feedback above. 2, The service users conducting the inspection and those engaged in it both appeared to enjoy the exercise, as did the inspector. 3, The inspector appreciated how this kind of inspection allowed him to get to know the service users better. This has improved communication for future inspections. 4, The service users appeared to be used, to and comfortable with, this kind of consultation, which indicated that consultation occurred regularly at this home. 5, Where service users could directly answer questions responses were generally positive. 6, That all the service users have something to contribute to the inspection process regardless of ability. This was also the case even where exercising the choice not to participate. 7, This was a good starting point for developing service user involvement. {Further details of the process and conclusions of the service user inspection pilot can be obtained via the lead inspector} What the service does well: 11 relative questionnaires were received none of which contained negative comments. Specific positive comments included: My brother is very well cared for, I am more than satisfied with his care.Dunheaved Lodge is very well run. Our family have always been very happy with our brother’s care at Dunheaved Lodge, it must be one of the best in Croydon. Evidence of Standards exceeded presented: Dunheve Lodge G53 S25779 DunhevedLodge V190557 150805 stage4.doc Version 1.40 Page 8 Standard 8. ‘Opportunities to participate in the day to day running of the home and to contribute to the development and review of policies, procedures and services’. At the 2003 announced inspection, most service users independently chose to join in with the inspection and confidently took over the manager’s role in responding to the inspector’s questions regarding the Standards. The service users acted as if this level of involvement was expected from them and was their right. The service users also confidently initiated their involvement at following annual inspections. {See also Standard 38.} This home’s practice gave the inspector the idea for the service user inspection that occurred this year in this and the other two homes in the group. Standard 36 ‘Supervision frequency’, was evidenced as exceeded for the last three years, this ensures a well guided and appraised staff group. Standard 38-‘The manager creating an open and inclusive atmosphere’ was evidenced as exceeded. {see Standard 8.} Service user inclusion, involvement and service user consultation are areas of consistent good practice for this home, and the service users’ familiarity with involvement in the home, was one of the reasons that this home was selected for the service user inspection pilot recorded under the summary. This provides further evidence that Standard 8 – ‘service user consultation and participation in the running of the home’ and Standard 38 – ‘ethos of the home’, are exceeded. Evidence of good practice presented: Standard 2.3 only requires internal assessments for privately funded service users. Although the home does not have privately funded service users, it still produces an internal assessment for all its potential new admissions, including the most recent referral. This creates a higher level of knowledge of the needs of a new service user. Standard 6. The implementation of Person-Centred Planning for all service users will make them more central to the process of care provision. Standard 14, The home has contributed towards the cost of service users holidays from its own funds which facilitates more holidays. Standard 15. The home has promoted positive and appropriate relationships and protected service users from inappropriate relationships. Two service users are now married and share a room and their own lounge. Standard 33- This home benefits from a stable and long standing staff group which provide consistency of staff who know the service users well. Standard 40, Although the relevant accessible documentation standards have now been met, the home continues to build on the current achievements, and to continually explore and develop access to all relevant documentation on an ongoing basis. What has improved since the last inspection? Dunheve Lodge G53 S25779 DunhevedLodge V190557 150805 stage4.doc Version 1.40 Page 9 This home is currently meeting almost all the National Minimum Standards. The home is to be commended for its commitment to meeting the Standards and its commitment to improve standards further. Standard 40, Although the relevant accessible documentation standards have now been met, the home continues to build on the current achievements, and to continually explore and develop access to all relevant documentation on an ongoing basis. Following service user consultation- a radio has been supplied for the kitchen, a vegetable patch ahs been created, new settees have been purchased and a printer has been purchased for the computer. 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. Dunheve Lodge G53 S25779 DunhevedLodge V190557 150805 stage4.doc Version 1.40 Page 10 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 Standards Statutory Requirements Identified During the Inspection Dunheve Lodge G53 S25779 DunhevedLodge V190557 150805 stage4.doc Version 1.40 Page 11 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 standard(s) 2. Prospective service users needs are assessed before they start at the home to ensure that all needs are known. EVIDENCE: As there has not been a new service user since the implementation of the care standards act, this standard cannot be fully assessed at this time. This standard is therefore graded with a ‘x’ to reflect that it could not be fully assessed at this time. Evidence of good practice presented; Standard 2.3 only requires internal assessments for privately funded service users. Although the home does not have privately funded service users, it still produces an internal assessment for all its potential new admissions, including the most recent referral. This creates a higher level of knowledge of the needs of a new service user. Dunheve Lodge G53 S25779 DunhevedLodge V190557 150805 stage4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, ,7, 8, and 9. Plans of care contain originally assessed needs and are updated regularly. This will help staff know all a resident’s needs and how to meet them. Service users are consulted on all aspects of life in the home and these views are implemented where appropriate. To facilitate this information regarding the home’s policies, activities and services, are produced in more accessible formats including pictorial versions. Risk assessments contain all the information required. Including this information could reduce unnecessary restrictions of liberty for the Service users. EVIDENCE: The home is implementing Person Centred Planning for all service users and all of the staff have now had initial training for this. Dunheve Lodge G53 S25779 DunhevedLodge V190557 150805 stage4.doc Version 1.40 Page 13 Individual plans are now therefore available to service users in a format they can understand. Plans of care are now written from the service users perspective, include simple language, and also include pictorial cues. The requirement and this standard are now both currently met. See also Standard 40 regarding good practice in accessible documentation. Evidence of good practice presented: Standard 6. Implementing Person-Centred Planning for all service users will make them more central to the process of care provision. Choices are only limited through involving the service user and relatives where appropriate. This is always through a risk assessment process and recorded in the service user’s file. No resident is able to manage their own finances but each has a cash-box and a lockable space in their rooms for security. Two service users are/have been subject to the Court of Protection; two service users have their finances looked after by relatives; and the proprietor is the appointee for nine service users. Service users participate in the day to day running of the home and contribute to the development and review of policies and services through regular meetings, individual discussions with their key workers, regular house meetings, the interviewing of new staff and service users can join nonconfidential sections of the staff handover meetings. See also the service user inspection pilot recorded in the summary for further supporting evidence. Service user inclusion and involvement is an area of good practice for this home and the service users’ familiarity with involvement in the home, was one of the reasons that this home was selected for the service user inspection pilot recorded under the summary. Choices are also respected and actioned as evidenced by the new radio in the kitchen, new printer, new settees and vegetable patch{ see Standard 39} Evidence of Standards exceeded presented; Standard 8. ‘Opportunities to participate in the day to day running of the home and to contribute to the development and review of policies, procedures and services’. At the 2003 announced inspection, most service users independently chose to join in with the inspection and confidently took over the manager’s role in responding to the inspector’s questions regarding the Standards. The service users acted as if this level of involvement was expected from them and was their right. The service users also confidently initiated their involvement at following annual inspections. {See also Standard 38.} This home’s practice gave the inspector the idea for the service user inspection that occurred this year in this and the other two homes in the group. Dunheve Lodge G53 S25779 DunhevedLodge V190557 150805 stage4.doc Version 1.40 Page 14 There are written procedures for unexplained absences. Service users are encouraged to take responsible risks and risk assessments are carried out in these areas, and involve the service user and advocates. Both individual and environmental risk assessments were observed in files sampled. When reducing choice with a view to protect a service user, risk assessments are completed to evidence of how safety outweighs choice in the specific area, and this is recorded in the care plan. Risk assessments to fully demonstrate how training and other options have been explored and how safety outweighs choice in the specific area before any restriction of liberty for the protection of the service user is implemented. A new pro-forma with written cues for staff in the above areas has now been implemented. Dunheve Lodge G53 S25779 DunhevedLodge V190557 150805 stage4.doc Version 1.40 Page 15 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 standard(s) 11, 12, 13, 15, 16, and 17. Service users’ have the opportunity for self-development, and are part of the local community. Service users’ are offered a healthy diet and have choices in meals offered. Service users’ are very well supported in maintaining appropriate relationships, so that their social lives are maximised within chosen boundaries. The daily routines and house rules promote service users’ rights, to ensure equality and that all rights are enjoyed by all residents. EVIDENCE: Speech therapy has been explored and service users have attended courses in body awareness and assertiveness. The service users are supported to maintain friendships, by being supported with building trust, flexible home visiting hours and the option to meet friends in private at the home. Dunheve Lodge G53 S25779 DunhevedLodge V190557 150805 stage4.doc Version 1.40 Page 16 The service users are encouraged to be as independent as possible and participate in cleaning their rooms, laundry, choosing and cooking meals and choosing trips and holidays. Some service users shop independently and the others are provided with support. Confidence is currently developed via providing a safe environment, building trust through appropriate support and community access and interaction. Opportunities for service users to participate in spiritual activities were evidenced and some service users have attended places of worship where this has been identified as their choice The manager has reported that: all service users are on the files of ‘Status’, an organisation that helps service users find employment; one service user has employment at The Links School and one service user is employed to provide support to the maintenance officer for all three homes in the group. Service users have attended South Norwood College where they undertook cookery, pottery, yoga, and computing. More recently taster groups have occurred leading to service users choosing further courses. The home provides its own day centre in Thornton Heath, which service users attend. The activities at the home’s day centre were observed during the first of this homes inspections of the three homes in this group. Activities at the daycentre included Adult Education and independent living skills. Accessing the local community is assisted by the home having its own car and mini bus. Main outings occur monthly and smaller trips occur on a weekly basis. The local parks, cafes, cinema, pubs, theatres, libraries, leisure centres, and shops are accessed. Service users have also attended clubs in the past. A number of service users were observed accessing the local community during the inspection. Staff are available to support service users while accessing the community. All service users are on the electoral register, and support has been offered to the service users to access the poling stations and engage in their civic rights in the past. This had also occurred for the recent elections with some visiting polling stations and others engaging in postal voting. Information about access rights, regarding the Disability Discrimination Act, is discussed during community activities where and when they arise. Family and friends are made aware of the home’s visiting policy and there are no restrictions regarding when family or friends can visit. Service users also visit their relatives and some stay overnight. Service users’ choices are respected and they can choose whom to, or not to, see. Service users have the opportunity to make friends who do not necessarily have their disability, through community use. Evidence was provided to confirm that staff have information and health training to support service users in making appropriate and informed decisions where they wish to develop close relationships, staff have ensured that this was mutually welcomed, where this is not welcomed or appropriate staff take appropriate action to protect the service user. Dunheve Lodge G53 S25779 DunhevedLodge V190557 150805 stage4.doc Version 1.40 Page 17 The menu was varied and included alternatives. The service users choose the menus with the assistance of the staff team. Breakfast is provided and a cooked breakfast is available at the weekend. Lunch is provided and service users have a packed lunch when they attend day centres. Supper is the main cooked meal of the day and snacks and drinks are provided. Laminated photographs of each meal have been produced and the relevant photograph is pinned to the notice board each day. See also Standard 40 regarding good practice in devising accessible documentation. Evidence of good practice presented: Standard 14, The home has contributed towards the cost of service users holidays from it’s own funds which facilitates more holidays. Standard 15. The home has promoted positive and appropriate relationships and protected service users from in-appropriate relationships. Two service users are now married and share a room and their own lounge. Dunheve Lodge G53 S25779 DunhevedLodge V190557 150805 stage4.doc Version 1.40 Page 18 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 standard(s) 18, 19, and 20. Service users’ personal care needs and physical and emotional health needs are met well by this home. This ensures that the residents’ physical and emotional health is well maintained and therefore the quality of life experienced is also maximised. Service users’’ medication is also well managed to ensure maximised good health. EVIDENCE: Direct personal care is currently provided for some service users at this home. Nursing care is not currently provided. Evidence has been presented of staff having knowledge of good practice in providing care and support and this was confirmed through observation. Personal care is provided in private, and timings of this are also flexible. A person of the same gender provides assistance with personal care where preference is recorded. Likes and dislikes are recorded on file and will be recorded in the new Person Centred Plans. The home provides consistency and continuity through designated key workers. All the service users have access to relevant specialist professional support to maximise independence including physiotherapy and speech therapy where required. Dunheve Lodge G53 S25779 DunhevedLodge V190557 150805 stage4.doc Version 1.40 Page 19 Access to opticians, dentists and audiologists was demonstrated. District nurses and other healthcare professionals attend when required. Visits from medical practitioners occur in private. Evidence was seen of regular monitoring of service users’ health. The service users are registered with a local G.P and have regular check ups. A record of all appointments and check ups are kept on the daily record sheets and monthly reports. The service users’ health is discussed at handovers and reviews. Part of the key worker role is to monitor the health needs of the service user. None of the current service users are able to self medicate. However, procedures and a lockable space in service users’ rooms are present to facilitate self-medication where appropriate. Medicine Administration Record sheets are kept in a locked metal cabinet. Medication is kept in a metal cupboard fixed to the wall. Individual blister packs are used for tablets instead of bottles for easy identification and monitoring. Homely remedies are only used where approved and known to the GP and records are kept. The home has a policy for the administration of medication. Staff who administer medication must have undergone professional training and passed an internal assessment. Staff are also required to check the possible side effects of any medication in the British National Formulary. The manager carries out their own spot checks to ensure the procedure is adhered to. Dunheve Lodge G53 S25779 DunhevedLodge V190557 150805 stage4.doc Version 1.40 Page 20 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 standard(s) 22 and 23. This home manages complaints well and there had been no complaints since the last inspection. The home’s policies and procedures relevant to this Standard currently facilitate protecting residents from abuse. EVIDENCE: There have been no complaints made to the home or to the Commission since the last inspection. The complaints procedure was produced in writing, and with ‘Widget’ computer programme symbols. See also Standard 40. The complaints procedure contained all the elements required to meet this standard, including clarification that the Commission can be contacted at any point in the complaints process. The home’s adult protection policy has been amended to make reference to contacting the commission and placing Local Authority in the event of any kind of abuse being suspected or alleged. The organisation has a Adult Protection procedure, a Whistle Blowing policy, an Aggression and Violence policy, and a Restraints policy and guidance, which includes appropriate record keeping guidance. The Gifts Policy does preclude staff from receiving gifts and the Wills Policy does preclude staff from being involved in the making of, or benefiting from service users’ wills. Dunheve Lodge G53 S25779 DunhevedLodge V190557 150805 stage4.doc Version 1.40 Page 21 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 standard(s) 24, and 30. The building, rooms and furniture generally meet the residents’ needs and provide a comfortable and safe environment which promotes independence. The home is hygienic and clean, homely and comfortable. This environment therefore facilitates the residents’ health and emotional well-being. EVIDENCE: The home has a maintenance book that records when an item requiring maintenance has been identified and when it was repaired. This indicates a timely response to maintenance issues identified. The home’s premises were in keeping with the local community. The premises were decorated in an appropriate style, reasonably maintained and were bright, airy and clean, and free from offensive odours. There was suitable domestic lighting and ventilation. Doors are sufficiently wide. Automatic ‘Magnetic’ fire door closing devises are present on fire doors. The grounds were well kept, and accessible to the current service user group. Dunheve Lodge G53 S25779 DunhevedLodge V190557 150805 stage4.doc Version 1.40 Page 22 The building was clean and tidy and was free of offensive odours. See also the service user inspection pilot recorded in the summary for further supporting evidence. The home has specific policies covering the disposal of clinical waste, control of infection, use of cleaning materials, hygiene, storage and preparation of food, communicable diseases, disposal of clinical waist, and dealing with spillages. There are Control Of Substances Hazardous to Health data sheets in their own file. Protective clothing was observed to be present. Laundry facilities have easily cleanable non-permeable floors and walls. Washing machines had appropriate programmes over 65 degrees to control risk of infection and a sluicing cycle. There is a separate sluice in it’s own room. The laundry room was positioned so that laundry does not need to be carried through the kitchen. Dunheve Lodge G53 S25779 DunhevedLodge V190557 150805 stage4.doc Version 1.40 Page 23 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34, 35, and 36. This home benefits from a stable and long standing staff group which provide consistency of staff who know the service users well. The home’s recruitment procedures protect the residents through vigorous staff vetting. Service users needs are well met by suitably experienced staff. Service users benefit from a well supervised staff team. EVIDENCE: The home can accommodate a total of 14 service users, assessed as having mild to moderate learning disabilities and medium overall care needs. The manager works 39 hours a week and there are a total of 270 care staff hours per week. In addition there are two sleeping in staff at night totalling 98 hours per week. There is a cook at 17.5 hours and a cleaner at 9 hours. This home has an equal opportunities recruitment policy. Criminal Record Bureau checks were available in staff files examined. staff do not start working with vulnerable adults until these have been acquired and assessed as satisfactory. External volunteers are not currently used at this home. Dunheve Lodge G53 S25779 DunhevedLodge V190557 150805 stage4.doc Version 1.40 Page 24 The staff files sampled contained interview notes, statements of terms and conditions, identification checks, copies of a passport and birth certificate or home office documentation, two written references and staff photographs. All staff have copies of the ‘General Social Care Council’ {GSCC} standards and code of conduct. All staff are subject to a 6-month probationary period which is reviewed at that time. The home has an Investors in People award. Learning Award Disability Framework induction and foundation training, to Skills Council specifications and targets, has been acquired and adopted by the home. The staff team receive regular monthly supervision, which is recorded on their files. Staff supervision includes translation of the home’s philosophy into work, monitoring work, support and professional guidance and identification of training needs, as required under Standard 36.4. All staff have an annual appraisal where their training needs are discussed. The home has regular staff meetings, which are recorded. Copies of the home’s grievance and disciplinary procedures are given to staff when they start and procedures required for dealing with physical aggression are in place. Supervision notes sampled identified that all staff had already exceeded the minimum annual requirement for 6 supervision sessions by about 50 . The manager also provides ad hoc as required ‘brief supervision’ and has an open door policy. Evidence of good practice presented: Standard 33- This home benefits from a stable and long standing staff group which provide consistency of staff who know the service users well. Evidence of Standards exceeded presented: Standard 36 ‘Supervision frequency’, was evidenced as exceeded for the last three years, this ensures a well guided and appraised staff group. Dunheve Lodge G53 S25779 DunhevedLodge V190557 150805 stage4.doc Version 1.40 Page 25 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38, 39, 40 and 42. The ethos, leadership and management of the home creates an open, positive, and inclusive atmosphere. The home’s quality assurance system involves the residents and relatives, and provides feedback to them, to allow them to be fully involved in improvements and measure improvements in the home for themselves. The home generally promotes the health and safety of the residents, so that practices and the environment do not place their health and safety at risk. EVIDENCE: The last three annual inspection reports recorded that notes of supervision sessions, residents meetings, and staff meetings indicated an open positive and inclusive management style. Dunheve Lodge G53 S25779 DunhevedLodge V190557 150805 stage4.doc Version 1.40 Page 26 During the 2003 inspection the service users arrived back and immediately pulled up a chair and independently chose to join in with the inspection. The service users confidently took over the manager’s role in responding to the inspector’s questions regarding the standards. The service users acted as if this level of involvement was expected from them and was their right. The service users also confidently initiated their involvement at this annual inspection. This evidences that the management approach to create an open, positive and inclusive atmosphere, has had a positive outcome for service users. See also Standard 8. Evidence of Standards exceeded presented; Standard 38-‘The manager creating an open and inclusive atmosphere’ was evidenced as exceeded.. {see above, standard 8 and See also the service user inspection pilot recorded in the summery.} There is a quality assurance system, which involves service users. The quality assurance tools include the complaints system, service user meetings, provider inspection visits, user satisfaction surveys, and an annual development plan open to service users through an annual quality assurance meeting. The user satisfaction surveys that have been devised are accessible and include written questions and pictorial cues. This has now been put into practice and has resulted in service user suggestions for improvement in quality being implemented. For example the home’s computer printer, radio in the kitchen, new settees and a vegdable patch. The following policies and procedures have all been made more accessible with simplified language and pictorial cues. The Complaints procedure, social contracts, service users guide, residence money procedure, smoking alcohol and drugs policy, sexuality policy, access to files policy, aggression towards staff policy, visits policy, adult protection policy, Staff code of conduct and the house rules. In addition there is a pictorial activities board and a pictorial menu. Evidence of good practice presented; Standard 40, Although the relevant accessible documentation standards have now been met, the home intends to build on the current achievements, and to continually explore and develop access to all relevant documentation on an ongoing basis. All of the health and safety policies and procedures relevant to this Standard were seen to be present. Fire Safety, First Aid, Food Hygiene, Infection Control, and Handling and Disposal of Clinical Waste policies are all also included in staff induction. Control Of Substances Hazardous to Health policies and data sheets were available and these substances were all locked away. All of the procedures and testing of systems required in Standard 42 were also present. Dunheve Lodge G53 S25779 DunhevedLodge V190557 150805 stage4.doc Version 1.40 Page 27 Dunheve Lodge G53 S25779 DunhevedLodge V190557 150805 stage4.doc Version 1.40 Page 28 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 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 4 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 3 3 3 x 3 3 3 Standard No 31 32 33 34 35 36 Score x x 3 3 3 4 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Dunheve Lodge Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x 4 3 3 x 3 x G53 S25779 DunhevedLodge V190557 150805 stage4.doc Version 1.40 Page 29 no 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 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. Refer to Standard 14 Good Practice Recommendations The home must provide a minimum 7 day holiday to all service users, which is inclusive of care, funded by the placing authority, as a part of the contracted price. Dunheve Lodge G53 S25779 DunhevedLodge V190557 150805 stage4.doc Version 1.40 Page 30 Commission for Social Care Inspection 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Dunheve Lodge G53 S25779 DunhevedLodge V190557 150805 stage4.doc Version 1.40 Page 31 - 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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