Inspection on 02/08/06 for Faro Lodge

This inspection was carried out on 2nd August 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 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 10/10/05

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 Roger Andrews Unannounced Inspection 2nd August 2006 13:30 Faro Lodge DS0000037563.V307910.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 Faro Lodge DS0000037563.V307910.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. Faro Lodge DS0000037563.V307910.R01.S.doc Version 5.2 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) www.norfolk.gov.uk Norfolk County Council-Community Care Ms Robyne Carman Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Faro Lodge DS0000037563.V307910.R01.S.doc Version 5.2 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. 1 service user (who is named in the Commission’s records) may be accommodated for a period of up to 6 months from October 16th 2005. 10th October 2005 4. Date of last inspection Brief Description of the Service: Faro Lodge was 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. The home has its own transport to support service users in accessing local 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.V307910.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Care services are judged against outcome groups, which assess how well a provider delivers outcomes for people using the service. The key inspection of this service has been carried out by using information from the providers, the service users as well as others who work at the service. This has included a recent announced visit to the service. This report gives a brief overview of the service and the current judgements for each outcome group. What the service does well: What has improved since the last inspection? What they could do better: There are a few things that could be improved at Faro Lodge. The paintwork in bedrooms and corridors needs redecorating. Some of the carpets are dirty and need cleaning or replacing. This will help Faro Lodge to look cleaner and brighter. The guests could be helped to know how to complain more easily by using the cassette tape which tells people how to do this. This could be helpful to guests who are not able to read very well. The staff have private meetings with the manager to help make sure they do their job as well as they can. These meetings should be held every two months. In some cases the support plans need to be filled in more fully. Faro Lodge DS0000037563.V307910.R01.S.doc Version 5.2 Page 6 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.V307910.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Faro Lodge DS0000037563.V307910.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 The quality outcome for this area is good. Guests are given relevant information and, in most circumstances, their needs are properly assessed prior to admission. EVIDENCE: The Statement of Purpose and the Service User Guide have been revised. The Service User Guide is well set out with useful information about, for example, the management of medication and guest’s finances during their stay. The documentation includes information about the admission process for prospective guests which includes coming to Faro Lodge to look around and to stay for meals before having an overnight stay. Full information is gathered on prospective guests and this process includes information from day services that guests attend and a ‘Getting to Know You’ form which prospective guests and their parents/carers complete. In some instances where guests pose more challenging behaviours it can be difficult for the staff to gain an accurate picture of support needs until the guest has been admitted. Comment has been made in previous inspection reports about ensuring that the support needs of guests can be met by the staff group. The requirement is not repeated in this report, though the expectation remains that the manager will continue to monitor and act upon inappropriate referrals to the service. There is a procedure for emergency admissions in place. Faro Lodge DS0000037563.V307910.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 The quality outcome for this area is good. Support plans are reasonably informative though in some cases need further completion work. Guests can exercise choice about their routine and preferences. Risk assessment processes are in place. EVIDENCE: A number of support plans were viewed at random. These contained a reasonable level of detail given that guests usually only stay at Faro Lodge on a short term basis of a few days or a week. Examples of areas covered include personal care, eating and drinking, communication and health issues. In addition to the support plans there are daily notes on each guest which reflect a good level of detail and give a good picture of activities that guests have been involved in. However, not all support plans have been fully completed and need further information or should indicate that incomplete sections are ‘not applicable’. See recommendation. Faro Lodge DS0000037563.V307910.R01.S.doc Version 5.2 Page 10 All guests have a moving and handling assessment and written comments were observed where specific levels of staffing are needed for particular clients. The manager has, in one instance, drawn up a management plan for one of the guests, though ideally these should be provided in advance of placements so that the staff are fully briefed on management protocols for individual guests prior to their arrival. From discussion with guests and staff it was evident that guests can make choices about what to do and where they spend their time. They are given a ‘satisfaction survey’ questionnaire to complete after each stay which asks how they were treated as well as requesting comments about food, bedtimes and other preferences. Faro Lodge DS0000037563.V307910.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 The quality outcome for this area is good. Guests have the opportunity to do interesting pastimes during their stay and have a varied menu. EVIDENCE: Guests come to Faro Lodge for short periods of time under normal circumstances, (i.e. a few days or a week). If possible they will continue to attend their usual day services. Leisure activities include ten-pin bowling, trips out to the coast, going into town and shopping. Activities can be decided upon at short notice, such as a weekend trip venue and guests will be involved in making these choices. There is a seven-seater vehicle available for outings. Support plans were noted to contain information about supervision levels for specific guests, e.g. when being taken out. Within Faro Lodge there are a variety of pastimes for guests to join in with or just watch television or listen to music. Each of the bedrooms has a television provided, though these may be removed in some cases depending on the support needs of specific individuals. The guests spoken to during the visit said they liked coming to stay at faro Lodge and many guests will have stayed several times previously. Faro Lodge DS0000037563.V307910.R01.S.doc Version 5.2 Page 12 The menu looks reasonably varied and on the day of the visit to Faro Lodge the evening meal was sausages, eggs, chips and beans. Special diets are catered for and one guest support plan identified a gluten free diet. The staff carry out the cooking tasks, though where able guests can be involved in making hot and cold drinks. Refer to comments later on about staffing. Meals will usually be taken at the table in the large kitchen/dining area. The menu is flexible and the manager and staff said that the menu could change depending on the requests of guests. Faro Lodge DS0000037563.V307910.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 The quality outcome for this area is good. Health needs are documented and monitored if required. Medication is properly stored and managed. EVIDENCE: Guests are able to be involved in their personal care to the extent they are able. One guest undertakes her own laundry and there is a utility room with domestic equipment. The healthcare needs of guests will primarily be dealt with at their usual home address and by their local G.P., though support plans contain appropriate information about medical conditions where necessary. The design of the premises allows disabled access. None of the guests staying during the inspection visit manage their own medication, though there is a pro-forma risk assessment document for this if guests do usually manage their own. The medication cabinet is in one of the offices and the keys to this cabinet are kept in a locked key cupboard. The medication records were viewed and were correct and up to date. Guests are informed in the pre-admission information that medication must be brought into Faro Lodge in its original container. Faro Lodge DS0000037563.V307910.R01.S.doc Version 5.2 Page 14 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 & 23 The quality outcome for this area is good. There is a complaints procedure, but the audio version could be more proactively used. Training has taken place on adult protection issues. EVIDENCE: The home has a complaints procedure operated by the proprietors who have a Compliments and Complaints Officer to oversee complaints about their services. There is an audio version of the complaints procedure on a cassette tape. However, this is rarely if ever used and it was suggested that staff are more pro-active in making this available to guests and part of the preadmission assessment could be to ensure that this information is communicated in audio form where appropriate for guests as a matter of course. See recommendation. An adult protection procedure is in place and staff have previously received training on this topic. Faro Lodge DS0000037563.V307910.R01.S.doc Version 5.2 Page 15 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 & 30 The quality outcome for this area is adequate. The décor and stained carpets detract from what would otherwise be a pleasant environment in which to stay. EVIDENCE: The most recent regulation 26 report undertaken by a representative of the county council notes that “There is a need for redecoration throughout Faro Lodge, especially the main corridor where the wall lights have been removed and in bedrooms where paintwork is marked and areas discoloured above radiators”. It was apparent that these comments have not been acted upon and, in addition to the observations about the corridors and bedrooms; the carpets in some of the communal areas have seen better days and need significant cleaning or, more preferably, replacement. One communal room contains a broken table, (which was awaiting repair), and a welsh dresser that has damaged drawers. These matters detract from what should be a high quality environment for guests and should be attended to. See recommendation. The environment does allow disabled access throughout the building and bathrooms and toilets are designed with this in mind. However, the equipment Faro Lodge DS0000037563.V307910.R01.S.doc Version 5.2 Page 16 in the bathroom is likely to be of specialised use to a minority of guests and does, unfortunately detract from a homely and domestic feel. As this is the only bathroom other guests have to use this equipment. Bedrooms are of a reasonable size and doors have locks. Guests can personalise their rooms to a small extent during their stay if they wish. There were no obvious safety hazards identified during a tour of the premises and there was no trace of any unpleasant odours. Chemicals and cleaning agents were securely locked a way. A risk assessment of the premises and equipment is carried out on a monthly basis which is recommended as good practice. Faro Lodge DS0000037563.V307910.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 35 & 36 The quality outcome for this area is good. Staffing is flexible, but needs to be monitored to ensure the needs of guests are met. Staff are properly recruited, though evidence of a Criminal Records Bureau check needs to be on every file. Staff have regular meetings and supervision, though the latter needs to be held on a two monthly basis. EVIDENCE: There is a certain degree of flexibility with the level of staffing provision though a member of staff did comment that when guests with more challenging behaviours are present this did detract to an extent from the attention staff could give to other guests. It was also commented upon that staff have to undertake the cooking duties and, particularly when preparing main meals, this can detract from their ability to give proper attention to the guests. This aspect was also noted and commented upon by the Council’s representative in his Regulation 26 visit report undertaken in July 2006who commented that “Members of staff raised concerns regarding needing to cook all the meals, ordering and buying food and carrying out stock checks, as it was felt this significantly increased the pressure of caring for guests and Faro Lodge DS0000037563.V307910.R01.S.doc Version 5.2 Page 18 ensuring their safety when only two members of staff are on duty. Another pressure was felt to be the twelve hour shifts which are undertaken”. These pressures need to be monitored and reviewed. It was reported that there are at least two members of staff on duty at night, one sleep-in and one waking. From comments and observations the staff have a good rapport with guests. Five staff have an NVQ certificate and one member of staff holds the Diploma in Social Work. Other training undertaken includes behaviour management, moving & handling, food hygiene, fire training and control restraint. The manager reported that a new training programme for staff is under development. Staff meetings take place on a regular basis and individual supervision sessions are now taking place, though in order to meet the National Minimum Standards these sessions should be taking place every two months as opposes to every three months as is currently the case. See recommendation. Several staff files were viewed at random and contained relevant recruitment information such as references, completed application forms and job descriptions. Some of the older files do not contain evidence of a Criminal Records Bureau check being carried out and confirmation that this has been done should be sent from the personnel department at County Hall for inclusion on the files where necessary. See requirement. Faro Lodge DS0000037563.V307910.R01.S.doc Version 5.2 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 The quality outcome for this area is good. The manager is experienced and qualified. Health and safety matters are attended to and records show that equipment, (such as fire detection systems), are checked and serviced regularly. EVIDENCE: The manager has considerable experience in working with people with learning difficulties and has undertaken both management and NVQ 4 training. The manager receives supervision from her line manager and also participates in a monthly meeting with the managers of other learning difficulty services. As noted, the views of guests are sought after each stay which helps in a quality overview of the service. The Council have also developed a five year business plan for its services for adults with a learning difficulty. Faro Lodge DS0000037563.V307910.R01.S.doc Version 5.2 Page 20 The fire records were looked at. The weekly test of fire points was up to date. Fire equipment is services annually and a fire risk assessment of the premises was undertaken in May 2006. A legionella risk assessment was carried out in January 2006. The finances of guests are kept is containers using a numbered tab system which helps prevent any unauthorised handling of guests’ money. Policies and procedures are in place and are kept in one of the offices. Some discussion took [place with the manager about how certain policies could be periodically reviewed with the staff group, (e.g. by having a ‘policy of the month’). Faro Lodge DS0000037563.V307910.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 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 2 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 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Faro Lodge DS0000037563.V307910.R01.S.doc Version 5.2 Page 22 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 YA34 Regulation 19 Requirement Evidence of a satisfactory Criminal Records Bureau check must be present on the file of each member of staff. Timescale for action 01/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA6 YA22 Good Practice Recommendations It is recommended that support plans are thoroughly completed and identify if sections are ‘not applicable’. It is recommended that the audio cassette with the complaints procedure be used more pro-actively with guests when they come to stay. It is recommended that the décor and damaged furniture is attended to and that stained carpets are either cleaned or replaced. It is recommended that staff receive supervision in line with the frequency identified in the National Minimum Standards, i.e. every two months. 3 YA24 4 YA36 Faro Lodge DS0000037563.V307910.R01.S.doc Version 5.2 Page 23 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.V307910.R01.S.doc Version 5.2 Page 24 - 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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