Inspection on 10/10/05 for Faro Lodge

This inspection was carried out on 10th October 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Faro Lodge 30/03/09

Faro Lodge 02/08/06

Faro Lodge 24/05/05

Faro Lodge 14/01/05

Faro Lodge 14/07/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Faro Lodge Galyon Road Kings Lynn Norfolk PE30 3YE Lead Inspector Mr Jerry Crehan Unannounced Inspection 10th October 2005 15.00 Faro Lodge DS0000037563.V257319.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Faro Lodge DS0000037563.V257319.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Faro Lodge DS0000037563.V257319.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Faro Lodge Address Galyon Road Kings Lynn Norfolk PE30 3YE 01553 679233 01553 679248 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) Norfolk County Council-Community Care Position Vacant Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Faro Lodge DS0000037563.V257319.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 8 service users may be accommodated of either sex and who have a learning disability and are aged between 18 and 65 years. That the manager of this establishment is responsible for the management of care to Service Users in this home only. The length of stay of a service user shall not exceed 28 days. Where there is a need for this condition to be waived, the provider will consult with the Commission for Social Care Inspection in advance, to agree and give reasons for any extension. One Service User, who is named in the Commission`s records, may be accommodated for a period of up to 6 months from December 27th 2004. 24th May 2005 4. Date of last inspection Brief Description of the Service: Faro Lodge was purpose built in 1999 to offer short term and respite care to adults with a learning disability. Owned and operated by Norfolk County Council it offers ground floor accommodation comprising 8 bedrooms, three communal lounge areas, dining room, kitchen, toilets and bathrooms. Faro Lodge is situated within a short distance of Kings Lynn town centre and is within easy reach of local amenities including shops and sports centre. There is easy access to local attractions, in particular the coastal town of Hunstanton and the royal home at Sandringham. The home has its own transport to support service users in accessing these facilities. Service users access a variety of day services and activities, often continuing to attend facilities accessed from their usual home or residence. Faro Lodge DS0000037563.V257319.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 3.5 hours. Opportunity was taken to tour the premises, look at care records and policies, talk to staff and the manager, and to talk to and observe service users. The home accommodated a total of four service users at the time of the inspection. What the service does well: What has improved since the last inspection? What they could do better: The registered person must be clear with the placing authority that the home should only accommodate service users who’s assessed needs it can demonstrably meet, that service users needs are compatible with one another, and that staff have the appropriate training and skills. Faro Lodge DS0000037563.V257319.R01.S.doc Version 5.0 Page 6 Care planning for service users with behaviour that challenges must be clearer and be drawn up with the involvement of relevant agencies/specialists, particularly where physical intervention is required. Staff deployment when providing one to one constant supervision for service users must provide the facility for staff breaks or recuperation from an intensive form of care delivery. Training provided in managing challenging behaviour is evidently not meeting staff and consequently service users needs. It is therefore welcomed that the proprietor is currently looking into the matter. 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. Faro Lodge DS0000037563.V257319.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Faro Lodge DS0000037563.V257319.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3&5 The home’s practice with regard to referrals of prospective service users does not adequately ensure needs (including specialist needs) and aspirations will be met. There are satisfactory arrangements for providing individual contracts. EVIDENCE: The manager provided evidence of a clear, and developing, assessment process for prospective service users that involves assessment by both the referrer and the home. It is also evident that this process involves service users and their carers. However, it is evident that the home’s policy and practice regarding referrals requires further work to ensure that needs, including specialist needs can be met, that service users needs are compatible with one another, and that staff have the appropriate training and skills (see requirement 1 & standard 6). Contracts seen are made between the placing authority and the service user, or their representative and copied to the home. Faro Lodge DS0000037563.V257319.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 8, 10 Individual needs and choices are promoted by the home. Care planning does not adequately reflect the care needs of some service users. EVIDENCE: Individual care plans are developed from assessment information provided by the placing authority, and from information provided by service users and their relatives in ‘getting to know you’ forms. Communication with service users provided evidence that staff are aware of assessed needs and provide assistance where necessary. It was also evident from this communication that service users are able to participate in a variety of aspects of life in the home, albeit that the service offers short-term care. The assessed needs for some service users at the home evidently require clearer established individualised procedures for behaviour that challenges. These procedures should be drawn up with the involvement of relevant agencies/specialists and incorporated within the care plan, thereby reducing risk to service users, care staff and others (see requirement 2). There are also concerns about the compatibility of the service users group and the risks associated to the health safety and welfare of service users with extremely diverse needs. Faro Lodge DS0000037563.V257319.R01.S.doc Version 5.0 Page 10 Confidentiality issues are evidently understood at the home. There are secure arrangements for the storage of records. Faro Lodge DS0000037563.V257319.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 13, 14, 16 The home caters adequately for the lifestyle of service users, albeit that the home offers relatively short periods of respite care. EVIDENCE: The majority of service users attend off site day services during their stay at the home. However, some service users remain at the home and participate in activities within the home within the local community. The home has also provided a day care service for some service users. The home provides transport to help service users maintain attendance at local clubs or other community venues, service users confirmed access to transport for trips into the local community and further afield. A service user spoken to indicated that they were able to maintain contact with friends independently of the home as part of an arrangement made between themselves and the home. Rights and responsibilities are respected and recognised at the home; service users have unrestricted access to all areas except other people’s bedrooms. All bedroom doors are lockable. Faro Lodge DS0000037563.V257319.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 Service users medication needs are well attended to. EVIDENCE: On review of medication records no discrepancies were identified. Both records and storage arrangements were satisfactory. Staff have access to appropriate safe handling of medicines training. At present there are no service users at the home with responsibility for managing their own medication. Faro Lodge DS0000037563.V257319.R01.S.doc Version 5.0 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 Arrangements for complaints are satisfactory, and service users are listened to and their concerns acted upon. EVIDENCE: The home has a complaints procedure operated by the proprietors who have a Compliments and Complaints Officer to oversee complaints about their services. The information provided by the home to prospective service users includes arrangements for making complaints, and there is a complaints booklet available in the foyer. Service users indicated that they felt able to speak to the manager or to staff if they had a concern or complaint. Faro Lodge DS0000037563.V257319.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 29, 30 A comfortable, accessible and safe standard of accommodation is provided, both internally and externally. EVIDENCE: The home provides a homely, comfortable and safe environment for the four (out of a potential eight) service users accommodated. Improvements to the home’s assisted bathing facilities were in process at the time of the inspection. Equipment assessments have recently been carried out and appropriate equipment to meet the moving and handling needs of service users and staff obtained. The home is kept very clean; there are good practices (and appropriate policies) to maintain hygiene. The home is free from offensive odours throughout. Faro Lodge DS0000037563.V257319.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33 & 35 There are concerns about the adequacy of staff deployment and training in meeting the diversity of need at the home. EVIDENCE: The home’s new manager supports and supervises an effective staff team. The manager indicated that they had recently appointed to vacant staff hours previously covered by the existing staff group. It is hoped that this will further contribute to the effectiveness of the staff team. However, it was evident at the inspection that two of the three care staff on duty during the evening were responsible for two service users requiring one to one supervision at all times. These arrangements provide little opportunity for staff breaks or recuperation from a clearly intensive form of care delivery (see requirement 3). As previously discussed there are also concerns about the compatibility of the service users group and the risks associated to the health safety and welfare of service users with extremely diverse needs (see requirement 4). Service users benefit from the access staff have to a variety of mandatory and other appropriate training. However, it was also apparent that staff at the home do not think they have access to the training they need in relation to the management of challenging behaviour (see requirement 5). The manager indicated that they have acknowledged this issue, which is being addressed by the proprietors. Faro Lodge DS0000037563.V257319.R01.S.doc Version 5.0 Page 16 Faro Lodge DS0000037563.V257319.R01.S.doc Version 5.0 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39, 40, 41 The systems for service user consultation are developing. The home’s policies and procedures provide reasonable safeguards for existing service users. EVIDENCE: The views of service users are sought on every day issues associated with the running of the home. In addition to this there are more formal means for the expression of views and comments. The manager indicated that they intend to promote and establish an advocacy group involved in monitoring and developing the home. The home and the proprietor to satisfactorily safeguard service users have developed a full range of appropriate policies and procedures. However, as previously stated, the home’s policy and practice regarding referrals requires further work to ensure that needs, including specialist needs can be met. The home demonstrated good record keeping practices ensuring service users confidentiality. Faro Lodge DS0000037563.V257319.R01.S.doc Version 5.0 Page 18 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 2 X 3 Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X 3 X 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X 3 3 LIFESTYLES Standard No Score 11 3 12 X 13 3 14 3 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X X 2 X 2 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Faro Lodge Score X X 3 X Standard No 37 38 39 40 41 42 43 Score X X 3 3 3 X X DS0000037563.V257319.R01.S.doc Version 5.0 Page 19 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA3 Regulation Requirement Timescale for action 10/10/05 2. YA6 3 YA33 4 YA33 5 YA35 12 The registered person must not (1)(a)&(b) offer a place to someone whose needs cannot be met by the home. This requirement is repeated 13(7) & The registered person must 15(1) ensure that care planning reflects the care needs of service users whose behaviour challenges. 18(1)(a) The registered person must ensure that suitably qualified competent and experienced persons are working at the care home in numbers appropriate for the health and welfare of service users. 13(6) & The registered person shall not 14(1)(d) provide accommodation at the care home unless they have confirmed the care home is suitable for the purpose of meeting the service users needs. 13(6) The registered person must &18(1)(c) ensure that staff receive training appropriate to the work they perform. 30/11/05 10/10/05 10/10/05 30/11/05 Faro Lodge DS0000037563.V257319.R01.S.doc Version 5.0 Page 20 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Faro Lodge DS0000037563.V257319.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Faro Lodge DS0000037563.V257319.R01.S.doc Version 5.0 Page 22 - 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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