Inspection on 22/10/07 for Dunheved Lodge

This inspection was carried out on 22nd October 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Dunheved Lodge 26/02/07

Dunheved Lodge 24/01/06

Dunheved Lodge 15/08/05

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 Dunheved Lodge 9 Dunheved Road North Thornton Heath Croydon Surrey CR7 6AH Lead Inspector Barry Khabbazi Key Unannounced Inspection 22 October 1st November 2007 09:30 Dunheved Lodge DS0000025779.V353621.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 Dunheved Lodge DS0000025779.V353621.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. Dunheved Lodge DS0000025779.V353621.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dunheved Lodge Address 9 Dunheved Road North Thornton Heath Croydon Surrey CR7 6AH 020 8665 6405 020 8665 9034 NO EMAIL www.bdcsupportingservices.co.uk Mr Cass Mohamedally Mrs Patricia Mohamedally Mr Eddy Muree Care Home 14 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) Category(ies) of Learning disability (14) registration, with number of places Dunheved Lodge DS0000025779.V353621.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 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. Dunheved Lodge DS0000025779.V353621.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The management of this home is currently in the process of changing and those changes will be fully reflected in the next report once the current manager has been de-registered and the new manager has been registered. This report is therefore based on the original manager still being officially the current registered manager. No significant negative outcomes of this change process were observed at this inspection. One possibly connected minor shortfall was identified, staff were using two care planning documents by mistake, one of which was an old version that did not fully meet the Standard. See Standard 6. It was reassuring to see that despite the changing situation, the service users still maintained the attitude that it was natural for them to be involved in the inspection process. This inspection was unannounced and started early in the day to allow the residents to be met, before they went to their day activities. As the manager was not available to provide information regarding some key standards {for example staff recruitment files}, a separate meeting with the area manager was also arranged. The area manager was interviewed, time was spent with the service users, and records, policies, care plans, and the building were also examined. The key Standards identified throughout this report were assessed at this inspection. This inspection also focussed on previously identified areas of good practice and any new areas arising. The home was found to be well run. There were no previous requirements set at the last inspection, and there was only one new requirement needed as a result of this inspection. See Standard 6. This home currently meets {and exceeds in some cases} most of the National Minimum Standards and has demonstrated many areas of good practice. Many of the areas of good practice identified refer to service user empowerment and involvement. These are priority areas for the Commission and also obviously for the service users. This view has been confirmed by the 2005 service user led inspection. See that report for details. All of the Commission’s service user and relative surveys have also confirmed this view, with only positive comments about the home being received to date. Discussions with service users on this occasion concluded that they were happy at the home, and liked the food and outings. The service users also talked about recent outings, including the cinema, dancing and a Monday club, and visits to relatives. Dunheved Lodge DS0000025779.V353621.R01.S.doc Version 5.2 Page 6 What the service does well: 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 in 2005 in this and the other two homes in the group. The service users still demonstrate this expectation of involvement. 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. 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. In addition new good practice has deen identified with monthly reviews also occurring. 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. Dunheved Lodge DS0000025779.V353621.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Dunheved Lodge DS0000025779.V353621.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Dunheved Lodge DS0000025779.V353621.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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. However, systems and additional assessments to that required are in place to facilitate the full assessment of a new resident. This Standard will therefore be considered met in principle. 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. Dunheved Lodge DS0000025779.V353621.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7, 8, and 9: Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. 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. However, a mix up which allowed some care plans to be written on old obsolete care planning forms means that not all needs are recorded on all care plans. Service users are supported to make decisions about their lives and these areas are recorded. Service users are well 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. Dunheved Lodge DS0000025779.V353621.R01.S.doc Version 5.2 Page 11 EVIDENCE: The service users each have a care plan generated from the comprehensive assessment completed by the care manager. All of a service user’s needs, how they are to be met and by whom, are recorded in their care plan or individual plan. However, a mix up allowed some care plans to be written on old obsolete care planning forms means that not all needs are recorded on these care plans. For example cultural or religious needs were not recorded. The following new requirement is set to address this: Care plans must all contain all the elements required under standard 6, and in particular cultural or religious needs. Care plans sampled had also been reviewed at least twice a year as required. In addition new good practice has been identified with monthly reviews also occurring. The home is implementing Person Centred Planning for all service users and all of the staff have now had initial training for this. 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. 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. Dunheved Lodge DS0000025779.V353621.R01.S.doc Version 5.2 Page 12 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. 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 last year in this and the other two homes in the group. It was reassuring to see that despite the changing management situation, {see summary} the service users still maintained the attitude that it was natural for them to be involved in the inspection process. 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 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 pro-forma with written cues for staff in the above areas has now been implemented. Dunheved Lodge DS0000025779.V353621.R01.S.doc Version 5.2 Page 13 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): Standards; 12 13, 14, 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 have the opportunity to be part of the local community and are able to take part in appropriate activities and holidays. This promotes inclusion and quality of life. Residents are supported in maintaining appropriate relationships, so that their social lives are maximised within chosen boundaries. Residents rights are respected and responsibilities recognises. The food provided is sufficient in quantity, and it is sufficiently nutritious which is important to ensure good health. EVIDENCE: Dunheved Lodge DS0000025779.V353621.R01.S.doc Version 5.2 Page 14 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. 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. The service users have recently started to do their own laundry as a part of promotion of independence skills. 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. Discussions with service users on this occasion concluded that they were happy at the home, and liked the food and outings. The service users also talked about recent outings, including the cinema, dancing and a Monday club, and visits to relatives. 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 had 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 College where they undertook cookery, pottery, yoga, and computing. More recently independent travel and independent living skills courses are being accessed. 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 home’s 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. 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. Dunheved Lodge DS0000025779.V353621.R01.S.doc Version 5.2 Page 15 The last inspection report contained the following recommendation: Each resident should be offered a seven-day holiday paid for by the home as a part of the contracted price. This has not occurred. However, it is recognised that the home has done all it can to bring this to the attention of the placing authorities and any further progress is now in their hands. 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. 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 inappropriate relationships. Two service users are now married. Two rooms were connected by a door being fitted between them. These have been converted into a shared room and a lounge for the couple. Dunheved Lodge DS0000025779.V353621.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19, and 20: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal care is carried out in a way that residents prefer so that dignity and choice are maintained, Residents’ physical health needs are met by this home. This ensures that the residents’ physical health is well maintained and therefore the quality of life experienced is also maximised. Residents’ medication is well managed as staff have had approved and accredited medication administration training to promote safer medication administration. EVIDENCE: Dunheved Lodge DS0000025779.V353621.R01.S.doc Version 5.2 Page 17 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. 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. Dunheved Lodge DS0000025779.V353621.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 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 feel their views are listened to and acted upon. This home manages concerns and complaints well, and there had been no complaints since the last inspection. The home’s policies and procedures relevant to this Standard generally facilitate protecting service users 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. Dunheved Lodge DS0000025779.V353621.R01.S.doc Version 5.2 Page 19 Dunheved Lodge DS0000025779.V353621.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards, 24, and, 30: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The building, rooms and furniture generally meet the residents’ needs and provide a comfortable and safe environment which promotes independence. The home is generally hygienic and clean, homely and comfortable. This environment therefore facilitates the residents’ health and emotional wellbeing. EVIDENCE: Dunheved Lodge DS0000025779.V353621.R01.S.doc Version 5.2 Page 21 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. 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 its own room. The laundry room was positioned so that laundry does not need to be carried through the kitchen. Dunheved Lodge DS0000025779.V353621.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 34, 35, and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents are supported by a staff group where 50 or more have the required qualifications. Achieving this raises the quality of staff, their knowledge and their practices. The home’s recruitment procedures protect the residents through vigorous staff vetting. Staff receive induction and foundation training to ensure that they are appropriately trained. The supervision frequency meets the minimum standard. The service users therefore benefit from a supervised staff team. EVIDENCE: Over 50 of staff have the required qualifications. This meets the ratio set out under Standard 32. Dunheved Lodge DS0000025779.V353621.R01.S.doc Version 5.2 Page 23 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 and these were of the required level and specific to the post. 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. The new staff file sampled contained, a Criminal Record Bureau check, 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. Learning Award Disability Framework induction and foundation training, to Skills Council specifications and targets, has been acquired and adopted by the home. Supervision records were available to confirm that supervision was occurring to the desired frequency but there were not enough records to re-confirm that previous exceeding of this standard had been maintained. 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. Dunheved Lodge DS0000025779.V353621.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 38, 39, and 42: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a well run home and the current registered manager has the required qualification. The ethos, leadership and management of the home creates a very 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 promotes the health and safety of the residents, so that practices and the environment do not place their health and safety at risk. Dunheved Lodge DS0000025779.V353621.R01.S.doc Version 5.2 Page 25 EVIDENCE: The management of this home is currently in the process of changing and those changes will be fully reflected in the next report once the new manger has been registered. This report is therefore based on the original manager still being officially the current registered manager. No negative outcomes of this change process were observed at this inspection. One possibly connected minor shortfall was identified, staff were using two care planning documents by mistake, one of which was an old version that did not fully meet the standard. See Standard 6. The current registered home manager has completed the required NVQ 4 and is suitably experienced to manage the home. 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 the last 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 referred to in the summary.} 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. Although the home has a Quality assurance system that meets the standard, new questioares are now a bit overdue. To reflect this proportionally the following recommendation is now set: New questionnaires should be provided to the service users. Dunheved Lodge DS0000025779.V353621.R01.S.doc Version 5.2 Page 26 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. Dunheved Lodge DS0000025779.V353621.R01.S.doc Version 5.2 Page 27 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 3 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 3 33 x 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 4 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 3 3 x x 3 x Dunheved Lodge DS0000025779.V353621.R01.S.doc Version 5.2 Page 28 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 YA6 Regulation 15[1] Requirement Care plans must all contain all the elements required under Standard 6, and in particular cultural or religious needs. Timescale for action 01/01/08 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 YA14 Good Practice Recommendations The home should 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. New questionnaires should be provided to the service users. 2 YA37 Dunheved Lodge DS0000025779.V353621.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Dunheved Lodge DS0000025779.V353621.R01.S.doc Version 5.2 Page 30 - 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. 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