Inspection on 17/08/05 for Fenton Lodge

This inspection was carried out on 17th August 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Fenton Lodge 10/05/07

Fenton Lodge 23/01/06

Fenton Lodge 16/11/04

Fenton Lodge 03/06/04

Fenton Lodge 02/07/02

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Southfields

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

CARE HOME ADULTS 18-65 Fenton Lodge Hazel Road Ash Green Surrey GU12 6HP Lead Inspector Sandra Holland Unannounced 17 August 2005 16:00 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Fenton Lodge H58-H09 S13640 Fenton Lodge V237624 170805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Fenton Lodge Address Fenton Lodge Hazel Road Ash Green Surrey GU12 6HP 01252 317211 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Pamela Mary Eales Wilco Poultry Farm, Tidmarsh Lane, Reading, Berkshire, RG8 8HA Mrs Rosemary Judith Diana Wykes Care Home (CRH) 3 Category(ies) of Learning disability (LD), 3 registration, with number of places Fenton Lodge H58-H09 S13640 Fenton Lodge V237624 170805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1 The age/age range of the persons to be accommodated will be 25 - 65 YEARS OF AGE Date of last inspection 16 November 2004 Brief Description of the Service: Fenton Lodge is a home for up to three people who have learning disabilities. The property is owned and maintained by the Thames And Chiltern Trust (TACT). The registered provider of care and support at the home is Mrs. Mary Eales, trading as Just Homes. Just Homes runs another home nearby and has four further homes in Surrey and Berkshire. The home is a detached bungalow, situated in a quiet residential cul-de-sac in Ash Green. Each resident is accommodated in a single bedroom and communal space is provided in a bright lounge. A large kitchen also includes a dining area and there are a number of toilets, a bathroom and a shower room. An office is available and is also used as a staff sleepover room. There is a large level garen to the rear of the home and car parking is available on the front drive. The home has access to local shops and community facilities in Ash, or in the larger nearby towns of Farnham, Guildford, Camberley, Aldershot and Farnborough. Fenton Lodge H58-H09 S13640 Fenton Lodge V237624 170805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was the first inspection to be carried out in the Commission for Social Care Inspection year April 2005 to March 2006. The inspection was carried out by Mrs. Sandra Holland, Lead Inspector for the service. Mrs. Conceicao (Sammy) Nowroozi, Deputy Manager was present representing the service. A full tour of the premises took place and a number of documents and records were examined, including individual plans, medication administration records (MAR), service user’s financial records and a selection of staff records. The inspector wishes to thank the service users and staff for their hospitality, time and assistance. Due to the complex nature of the service users’ needs at the home and their limited verbal communication, it was not possible for the inspector to communicate directly with them. Most of the information for this report was therefore obtained from speaking to staff, looking at records and observing the body language and facial expressions of service users. What the service does well: What has improved since the last inspection? It was not possible to assess whether the requirements from the last inspection had been met as the manager was not present. Fenton Lodge H58-H09 S13640 Fenton Lodge V237624 170805 Stage 4.doc Version 1.40 Page 6 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. Fenton Lodge H58-H09 S13640 Fenton Lodge V237624 170805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Fenton Lodge H58-H09 S13640 Fenton Lodge V237624 170805 Stage 4.doc Version 1.40 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 standard(s) These standards were not assessed. EVIDENCE: Fenton Lodge H58-H09 S13640 Fenton Lodge V237624 170805 Stage 4.doc Version 1.40 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 standard(s) 6, 7 and 9. Effective and comprehensive individual plans are in place to guide staff to the support needs of each service user. EVIDENCE: Detailed individual plans of all aspects of the support needs of the service users have been drawn up. These were seen to include a photograph of the service user, family contacts, healthcare professionals involved in supporting the service user, behavioural guidelines, communication methods and details of review meetings. The individual plans included a record to show when the plan had been reviewed, and this was seen to have been carried out on a regular basis. Staff advised that service users are supported to maintain and develop their independence and are encouraged to make personal choices. Service users are supported to choose their own activities, food and to handle their own finances, in as much as they are able. Any areas of risk to the health and welfare of the service users, such as the risks involved in bathing, travelling in the car or taking prescribed medication are identified, assessed and recorded, staff advised. Service users are Fenton Lodge H58-H09 S13640 Fenton Lodge V237624 170805 Stage 4.doc Version 1.40 Page 10 supported to be as independent as possible with reference to the level of risk identified. The risk assessments seen had been regularly reviewed. Fenton Lodge H58-H09 S13640 Fenton Lodge V237624 170805 Stage 4.doc Version 1.40 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 standard(s) 13, 15, 16 and 17. Service users are supported by staff to lead active and fulfilled lives. EVIDENCE: It was clear that service users are supported to be active and involved in the local community. At the time of inspection, one service user was out shopping for personal items in a local town shopping centre with a member of staff. Another service user had gone directly from a day centre to have tea with a friend living at another home in the group. Staff advised that service users enjoy their holidays away from the home and service users had recently returned from a holiday in Norfolk, accompanied by staff. All three of the service users have involvement with their families, staff stated. Each has regular contact with their family, either at the home or at their family’s home. One service user is actively supported by staff and is taken to visit her mother who resides in a nursing home. It was pleasing to see that a written record is maintained of the communication and contact between service users and their families and friends. Fenton Lodge H58-H09 S13640 Fenton Lodge V237624 170805 Stage 4.doc Version 1.40 Page 12 Staff were seen to respect service users’ rights and did not allow access to their rooms without their agreement, or in their absence. Staff included service users in conversations about the household activities being carried out. The evening meal was seen provided in an appropriate form for each individual and eaten family style in the dining room along with staff. Staff advised that one service user prefers to eat alone in their room and this choice is respected, accommodated and was seen to be recorded in the individual plan. Fenton Lodge H58-H09 S13640 Fenton Lodge V237624 170805 Stage 4.doc Version 1.40 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 standard(s) 18, 19 and 20. Service users receive appropriate personal support. Their healthcare needs are well met. EVIDENCE: It was clear from observing service users and staff together, that personal support is provided according to the needs of the individual and in the way that the service users prefer. Personal support was given sensitively and discreetly and service users were spoken to in a respectful manner. From the individual plans and speaking to staff, it was evident that a number of healthcare professionals are involved in the support of the service users. These include general practitioners (G.P.), community nurse, continence nurse, chiropodist and dentist. Staff advised that the chiropodist visits the home and service users go out to attend appointments with the dentist and G.P., if well enough. Staff advised that medication administration is arranged through a local branch of a national pharmacy chain. Individual medications are supplied in “blister” packs and administration is recorded on medication administration record (MAR) sheets. Two shortfalls in the administration of medication were noted: • It was not possible to check that the stock held accurately matched the record held, because details of stock held in the home had not been carried forward. Fenton Lodge H58-H09 S13640 Fenton Lodge V237624 170805 Stage 4.doc Version 1.40 Page 14 • A medication had been administered to a service user in error. No record of the error was seen in the service user’s individual plan. The administration of medication must be reviewed to ensure that the stocks and records held in the home can be checked for accuracy, an audit trail followed and to prevent a recurrence of the administration error. A requirement has been made. Fenton Lodge H58-H09 S13640 Fenton Lodge V237624 170805 Stage 4.doc Version 1.40 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 23. Staff are aware of their responsibility to protect service users. One aspect of record keeping in relation to service users’ finances needs to be improved, to protect service users. EVIDENCE: From speaking to staff and from records held it is clear that staff are aware of their role in protecting service users. Staff spoken to stated that they would report any concerns that they had and were aware of the process to follow. On examination of the records of service user monies held for safekeeping, it was noted that some of the entries in the ledger had only been signed by one member of staff. This does not adequately protect service users or staff. A recommendation has been made. Fenton Lodge H58-H09 S13640 Fenton Lodge V237624 170805 Stage 4.doc Version 1.40 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 28, 29 and 30. The décor of the home provides a comfortable and homely environment for those living there. EVIDENCE: The home is situated in a quiet residential area of Ash Green. The home has it’s own vehicle as private transport is necessary to access local shops, pubs, public transport and other facilities. The home is cheerfully decorated and is well maintained and furnished. An attractive garden is available at the back of the house and has a number of chairs and tables. Pet rabbits and a pond with fish were seen in the garden, and staff advised that service users are supported to care for them. It was pleasing to see effective systems in place in the kitchen • Sharp items and substances hazardous to health in use in the kitchen were locked away immediately after use. • Record keeping in relation to food storage and cooking was well maintained. • A temperature probe is used to record the temperature of hot food served and this was seen along with antiseptic wipes with which to clean it. Fenton Lodge H58-H09 S13640 Fenton Lodge V237624 170805 Stage 4.doc Version 1.40 Page 17 • All food items in the fridge were covered and labelled with the date of opening. Two service users were happy to show their bedrooms and these have been personalised with their own belongings, including televisions, music facilities, pictures and ornaments. The deputy manager stated that all service users are mobile, but specialist equipment or adaptations are provided as necessary, following appropriate assessment. A number of adaptations to assist service users have been provided, including handrails in the corridors and grab handles in the toilets and bathrooms. An easy access bath and a level entry shower are available and a raised toilet seat has been provided to assist one service user. All areas of the home were seen to be clean, hygienic and freshly aired. Fenton Lodge H58-H09 S13640 Fenton Lodge V237624 170805 Stage 4.doc Version 1.40 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35 and 36. Service users are supported by a committed and enthusiastic team of staff. EVIDENCE: The service users are supported by a small team of support staff under the leadership of the manager and her deputy. Staff advised that they all share the support tasks within the home, including shopping, cooking, laundry and assisting with personal care. From the rota and speaking to staff, it was noted that some staff work a large number of hours or shifts. A staff member advised that she had signed a Working Time Directive (WTD) disclaimer, to indicate that she is willing to work hours above the recommended level. Whilst this ensures continuity of support for service users and reduces the need for agency or bank staff, it is not advisable long term. Working excess hours may affect the health of staff or their effectiveness and safety when at work. The record was seen, of the detailed induction undertaken by a recently recruited member of staff, which is linked to specific training for staff who support with people with learning disabilities (LADAF). Fenton Lodge H58-H09 S13640 Fenton Lodge V237624 170805 Stage 4.doc Version 1.40 Page 19 A number of staff have taken, or are undertaking National Vocational Qualification (NVQ) training courses and the home is on target to meet the required ratio of 50 of trained care staff. Staff stated that formal supervision meetings are held on a regular basis and to the required frequency. A record of the planned meetings is openly accessible on the rota and in the diary. A requirement has been made. Fenton Lodge H58-H09 S13640 Fenton Lodge V237624 170805 Stage 4.doc Version 1.40 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38, 41 and 42. Service users of the home, benefit from an open and inclusive ethos and effective management of the home. EVIDENCE: Although the manager was not present during the inspection, it was evident from the standard of the premises and the approach of staff, that the home is effectively managed. It was also clear that the manager has developed the staff team to manage the home in her absence. The deputy manager was able to assist the inspector and provide much of the information required. Three shortfalls were noted in the required standard of record keeping: • It was noted that a Regulation 37 notification had not been received by CSCI in respect of the error in the administration of medication to a service user. The deputy manager stated that she did not know where to find copies of Regulation 37 forms, in the event they were needed. • Erasing fluid had been used to make alterations to the staff roster • Some entries in the ledger, which is used to record service users’ financial transactions had been signed by one person only. Fenton Lodge H58-H09 S13640 Fenton Lodge V237624 170805 Stage 4.doc Version 1.40 Page 21 During the tour of the premises, it was observed that a radiator in the bathroom, close to the bath and handrails, was not covered to protect service users from burning. Requirements have been made. Fenton Lodge H58-H09 S13640 Fenton Lodge V237624 170805 Stage 4.doc Version 1.40 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 ENVIRONMENT Score x 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 x x 3 x 3 3 3 Standard No 31 32 33 34 35 36 Score x x 2 x 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Fenton Lodge Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score x 3 x x 2 2 x H58-H09 S13640 Fenton Lodge V237624 170805 Stage 4.doc Version 1.40 Page 23 Not assessed. 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 20 Regulation 13 (2) Timescale for action The registered person shall make 16th arrangements for the recording, September handling, safekeeping, safe 2005 administration and disposal of medicines received into the care home. 16th The registered person shall, having regard to the size of the September 2005 care home, the statement of purpose and the number and needs of the service users, ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of serivce users. The registered person shall 16th maintain in the care home the September records specified in Schedule 4. 2005 Specifically, a copy of the duty roster of persons working at the care home and a record of whether the roster was actually worked. The use of erasing fluids to make alterations must not be permitted. The registered person shall give 16th notice to the CSCI without delay September of the occurrence of any event in 2005 Version 1.40 Page 24 Requirement 2. 33 18(1)(a) 3. 41 17 (2) Schedule 4 4. 41 37 Fenton Lodge H58-H09 S13640 Fenton Lodge V237624 170805 Stage 4.doc 5. 42 13(4)(a) the care home which adversely affects the well-being or safety of any service user. The registered person shall ensure that all parts of the care home to which service users have access are so far as reasonably practicable free from avoidable risks. 16th September 2005 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 41 Good Practice Recommendations It is good practice to ensure that all transactions of service users monies are handled and signed by two members of staff. Fenton Lodge H58-H09 S13640 Fenton Lodge V237624 170805 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Fenton Lodge H58-H09 S13640 Fenton Lodge V237624 170805 Stage 4.doc Version 1.40 Page 26 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!