Inspection on 23/01/06 for Fenton Lodge

This inspection was carried out on 23rd January 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Fenton Lodge 10/05/07

Fenton Lodge 17/08/05

Fenton Lodge 16/11/04

Fenton Lodge 03/06/04

Fenton Lodge 02/07/02

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Insight - Eastchurch

Southfields

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Dovedale Court

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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 Fenton Lodge Hazel Road Ash Green Surrey GU12 6HP Lead Inspector Suzanne Magnier Unannounced Inspection 10:00 23 and 24 January 2006 rd th Fenton Lodge DS0000013640.V273465.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 Fenton Lodge DS0000013640.V273465.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. Fenton Lodge DS0000013640.V273465.R01.S.doc Version 5.0 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 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) Mrs Pamela Mary Eales Mrs Rosemary Judith Diana Wykes Care Home 3 Category(ies) of Learning disability (3), Old age, not falling registration, with number within any other category (1) of places Fenton Lodge DS0000013640.V273465.R01.S.doc Version 5.0 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 17th August 2005 Date of last inspection 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 DS0000013640.V273465.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over 2 days as the Registered Manager was unavailable at the home on the 23rd January 2006 and the inspector returned on the 24th January 2006 to meet with them. The inspection on the 23rd January was conducted with a support worker. The main focus of the inspections was to ascertain that the previous requirements and standards not assessed during the unannounced inspection in August 2005 had been met. One resident was at home on both days of the inspection and the inspector met with several members of staff. Due to the complexity of the residents needs it was difficult to obtain direct feedback from the resident. Therefore, observations of behaviour and ways of communicating were noted during the inspection. A partial tour of the premises took place and several documents and records were examined, including an individual care plan, medication administration records (MAR), staff recruitment files, several policies and procedures and reporting of incidents and accidents. The inspector wishes to thank the residents and staff for their hospitality and assistance during the inspection. What the service does well: Throughout the inspection the inspector observed staff supporting residents in a manner, which reflected dignity and respect. The home is clean and has a homely atmosphere and continues to be well managed and staff morale is high. The home continues to provide a high standard of care and support to the residents with the aid of clear and updated plans of care. The home uses pictures and see read cards in a variety of ways which assist residents in having choice and control over their lives through effective communication. Changes in the needs of residents are clearly identified and additional health care support sought. There is an open and friendly atmosphere in the home, which reflects the competency of the staff in supporting residents in and efficient and effective manner. Staff training and recruitment practices are of the expected standard. Training, recruitment and policies and procedures in the home protect residents as far as reasonably practicable. Fenton Lodge DS0000013640.V273465.R01.S.doc Version 5.0 Page 6 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. Fenton Lodge DS0000013640.V273465.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 Fenton Lodge DS0000013640.V273465.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): 1,2,3,4,5. The home has developed pictorial information in the Statement of Purpose and the Service Users Guide, which would be helpful for prospective residents, and their representatives in choosing residency at the home. The homes admission procedure includes a full assessment of the person needs and terms and conditions, and contracts have also been developed in pictorial form to assist residents in understanding their tenancy rights. EVIDENCE: There have been no admissions to the home since the previous inspection. The inspector sampled the homes Statement of Purpose and Service Users guide both of which contained the information, which would assist prospective residents, or their representatives to have information regarding the facilities and care offered at the home. The Service Users Guide, which had been developed in pictorial form, was observed in each resident’s bedroom on a notice board. The homes admission procedure indicated that any prospective resident could visit the home prior to residency and trial periods of residency are offered which include day and overnight stays and weekend visits. The support worker explained that a full care needs assessment is carried out prior to admission to the home. The inspector sampled that all residents had a contract of residency from the local Authority and the terms and conditions of residency had also been developed in pictorial form. Fenton Lodge DS0000013640.V273465.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. The home continues to provide a high standard of care and support to the residents with the aid of clear and updated plans of care. Changes in the needs of residents are clearly identified and additional health care support sought. The inspector noted that the homes confidentiality policy had been recently updated. EVIDENCE: During the course of the inspection the inspector was advised that there had been recent concern regarding the changing needs of one resident in the home. As a result of the residents changing needs it was evident through sampling the residents care plan, risk assessments, behaviour monitoring forms and other health care records, that the home has continued to work closely with a variety of health care professionals in assessing the support needs of the resident. The inspector was advised that each resident in the home has an understanding of their daily routine and for those residents with communication difficulties the staff offer support through pictorial cards, which the inspector sampled. The inspector was told that residents are supported to maintain and develop their independence and are encouraged to make personal choices. Fenton Lodge DS0000013640.V273465.R01.S.doc Version 5.0 Page 10 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): 11,12,14. The residents are supported to exercise choice about their daily lives and are supported in a caring and professional manner. EVIDENCE: On arrival at the inspection two of the residents were out and one resident was attending an activity club held in their home. The following day the same two residents were out and the inspector met with the remaining resident who had come back from attending a GP appointment and was getting ready to have a cup of tea prior to going shopping with the Deputy Manager. The inspector noted that the staff supported the resident in a professional and caring manner and had a good understanding of their ways of communication including what tone, sounds and actions meant. The residents care plans document a section regarding choice and independence with each resident having an activity plan. The plans include choices of clothes to wear, weekly choice of menus and other community activities. It has been recommended that where goals have been agreed with residents there are clear records to indicate the resident’s achievements and these are shared with the resident. Fenton Lodge DS0000013640.V273465.R01.S.doc Version 5.0 Page 11 The staff member advised that the residents enjoyed a holiday in Norfolk last year and one resident had already made reservations for a summer holiday in Bognor for this year accompanied by staff. Fenton Lodge DS0000013640.V273465.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): 19,20,21. The home continues to provide a high standard of care and support to the residents with the aid of clear and updated plans of care. The medication requirements from the previous inspection have been met. EVIDENCE: The inspector sampled a resident’s records, which included monitoring of the persons sleeping pattern due to their disturbed sleep. In consultation the persons Care Manager and a review of the residents care plan additional staff funding had been agreed in order to meet the needs of the resident. The requirements made at the previous inspections have been met as the home has developed a medication stock taking procedure. All the records sampled were in good order. The inspector sampled a recently updated policy and procedure in the event of a resident’s death; one residents care plan detailed their wishes regarding their final affairs. Fenton Lodge DS0000013640.V273465.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, 23. The staff were attentive, ensured residents protection and actively listened to the resident at home during the inspection. A variety of written compliments had been received by the home. EVIDENCE: The inspector observed that in each resident’s bedroom a pictorial complaints procedure was available for each resident. The Registered Manager told the inspector that the home had not received any complaints. There were several letters of compliment, which had been received by the home from relatives, contractors visiting the home and health care professionals. The inspector sampled the resident’s money ledger and noted that the home had improved the way of recording transactions in order to safeguard the residents from financial abuse. In consultation with a resident’s Care Manager and other health care professionals the home have ensured the safety of one resident by implementing a procedure which could be viewed as an infringement of the residents rights of movement. The home has developed a clear written procedure which details when the resident is to be supported into their wheelchair, how long the support will last and what activities are available for the resident which includes listening to relaxing music. It has been recommended that when the support is needed that the staff document the residents response and how effective the support has been in diffusing behaviour which may cause injury to the resident or others in the home. Fenton Lodge DS0000013640.V273465.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): 30. The home continues to provide a comfortable and homely environment for those living there. Due to wear and soiled areas it is required that the office carpet is cleaned or replaced. EVIDENCE: All areas of the home were observed to be clean, homely and favourably decorated. The inspector noted that the office carpet was soiled and the carpet leading into the office was worn, it is required that the carpet is cleaned or replaced in order to reflect the high standard of decoration and cleanliness throughout the home. Fenton Lodge DS0000013640.V273465.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): 31,32,33,34. There is an open and friendly atmosphere in the home, which reflects the competency of the staff in supporting residents in and efficient and effective manner. Staff training and recruitment practices are of the expected standard. EVIDENCE: The staff on duty over the two days of the unannounced inspection demonstrated a good knowledge of the needs of the residents and the smooth running of the home. One member of staff explained to the inspector that one resident is aware of who the Manager is and tells other staff that the Manager is in the home. A staff file sampled by the inspector demonstrated that the home has an ongoing programme of training and the staff file sampled evidenced that the staff member had undertaken all mandatory training. The inspector was advised that two staff were awaiting their certificates for completion of NVQ level 2 and the Registered Manager had nearly completed the Registered Managers Award. The inspector sampled a staff file of a person newly appointed. The staff file contained all the relevant and appropriate records regarding recruitment and safe vetting of staff in order to protect residents. Fenton Lodge DS0000013640.V273465.R01.S.doc Version 5.0 Page 16 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): 37,39,40,41,42,43. The home continues to be well managed and staff moral is high. Training, recruitment and policies and procedures in the home protect residents as far as reasonably practicable. It is required that Regulation 37 notifications are sent promptly to CSCI. EVIDENCE: Staff told the inspector that the Registered Manager was ‘the best’ and worked alongside staff on shifts, was well respected and managed the home well. It was evident that the staff were efficient in the running of the home and that the management style was open and inclusive. Staff morale was noted as high. During the inspection it was observed that residents were included in decision making in their home. The inspector sampled residents meeting minutes, which indicated also that residents were included in decisions and choices in their home and their lives. Fenton Lodge DS0000013640.V273465.R01.S.doc Version 5.0 Page 17 The homes policies and procedures were well written and kept up to date, in addition they were accessible to staff for reference. The inspector sampled two residents finance transaction books and receipts. The homes policy of recording all transactions to ensure that safe keeping of resident’s funds was noted as efficient. Whilst sampling a residents files and the accident/incident book the inspector raised concern regarding the homes procedure of reporting Regulation 37 notifications to CSCI. It was noted that one resident had sustained several falls, one of which had occurred on the day of inspection, and additionally a report of one resident striking another. A staff member advised the inspector of the homes reporting procedure and was unaware if the incidents had been reported to CSCI. It was agreed that the inspector would return to the home the following day to clarify the matter with the Registered Manager. On the 24th January 2006 the inspector met with the Registered Manager and during the consultation it became apparent that several incidents had not been reported to CSCI under the Care Homes Regulations (as amended) 2001. The inspector has required that the Registered Manager inform by letter to CSCI all events, in retrospect from September 2005 that have affected the wellbeing and welfare of the residents. The Registered Manager showed the inspector the homes budget and demonstrated a clear understanding of the homes budget. Fenton Lodge DS0000013640.V273465.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 3 3 3 3 3 Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X 3 X 3 Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X 2 LIFESTYLES Standard No Score 11 2 12 3 13 X 14 3 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score 3 3 3 3 X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Fenton Lodge Score X 3 3 3 Standard No 37 38 39 40 41 42 43 Score 3 X 3 3 3 2 3 DS0000013640.V273465.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? NO 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 YA24 Regulation 23.(2)(d) Requirement The Registered Person must ensure that the office carpet is cleaned or replaced in order that to reflect the high standard of decoration and cleanliness throughout the home. The Registered Person must give notice to the C.S.C.I without delay of any event in the care home, which adversely affects the well-being, or safety of any resident. Timescale for action 25/04/06 2 YA42 37.(1)(e) 25/01/06 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 Refer to Standard YA11 Good Practice Recommendations It has been recommended that where goals have been agreed with residents there are clear records to indicate the resident’s achievements and these are shared with the resident. It has been recommended that when specific support is needed for a resident that staff document the residents response and how effective the support has been in DS0000013640.V273465.R01.S.doc Version 5.0 Page 20 2 YA23 Fenton Lodge diffusing behaviour which may cause injury to the resident or others in the home. Fenton Lodge DS0000013640.V273465.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Surrey Area Office 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. 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