Inspection on 08/06/06 for Fir Lodge

This inspection was carried out on 8th June 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Fir Lodge 08/10/05

Fir Lodge 25/05/05

Fir Lodge 24/01/05

Fir Lodge 16/06/04

Similar services:

2 Perhaver Park

The Vicarage

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

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

CARE HOME ADULTS 18-65 Fir Lodge 91 Bloomfield Avenue Bath Bath & N E Somerset BA2 3AE Lead Inspector David Smith Key Unannounced Inspection 8th June 2006 09:30 Fir Lodge DS0000008180.V299252.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 Fir Lodge DS0000008180.V299252.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. Fir Lodge DS0000008180.V299252.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fir Lodge Address 91 Bloomfield Avenue Bath Bath & N E Somerset BA2 3AE 01225 421241 01225 421241 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.dimensions-uk.org Dimensions (UK) Ltd Mrs Elizabeth Black Care Home 5 Category(ies) of Learning disability (3), Physical disability (2) registration, with number of places Fir Lodge DS0000008180.V299252.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 5 bed home currently registered for 5 people with learning and / or physical disabilities. 8th October 2005 Date of last inspection Brief Description of the Service: Fir Lodge is operated by Dimensions (UK) Ltd, an independent voluntary organisation. The home is a spacious Victorian house situated in a quiet location, and provides easy access to local shops on Bear Flat and Moorland Road. The city centre is also no more than a mile away. Accommodation is provided on three floors. There are six single bedrooms in total, one on the ground floor, which has ensuite facilities, and four on the first floor, one with ensuite facilities and another with a through floor lift, which was installed specifically for the person who occupies this bedroom. Staff members provide sleep-in cover and use the sixth bedroom, which is on the second floor. There is also an office and a kitchen on the second floor. A communal lounge area, a dining room, kitchen and laundry area are located on the ground floor. There are two bathrooms with toilets, one on the first floor and one on the second floor. There is also an additional communal toilet on the ground floor. The home is set in its own grounds and there is a garden with a patio area, which can be accessed by wheelchair down a path, which runs along the side of the house. The home has its own mini-bus, which enables access to the wider community. Fir Lodge DS0000008180.V299252.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a Key Inspection carried out over one day. The inspector gathered evidence for this report through discussions with the registered manager, care staff and observation of interaction and communication between staff and people who live in the home. Two individuals who live in the home spoke with the inspector and two families returned comment cards in relation to the service their relatives receive. Care plans and associated records were examined, together with staff records, risk assessments and health and safety records. The inspector was also provided with a tour of the home. The people who live in the home wish to be described as “people who live in the home”, or “individuals”, rather than service users. Dimensions (UK) Ltd uses the term “people we support”. This terminology has therefore been acknowledged and replaced the term “service user” in this report. What the service does well: Two individuals spoken with spoke highly of the home and its staff team. They both expressed they are happy living in the home. The two families who responded were complimentary regarding the quality of service their relative received and towards the manager and staff team in general. The home promotes a person centred approach and remains committed to improving this area to ensure individuals are supported to determine their own service. The service works actively with external agencies and Health Care Professionals to develop and improve the support provided to people who live in the home. Fir Lodge DS0000008180.V299252.R01.S.doc Version 5.2 Page 6 Care plans and guidelines remain well written and informative. This helps to ensure consistent support for each person who lives in the home. There is a strong core of committed staff who are well supported by a manager who is dedicated and able. Staff are responsive to each individual’s needs. What has improved since the last inspection? What they could do better: The home should review/update its Statement of Purpose and Service Users Guides. This would ensure both accurately reflect the service provided by the home to all stakeholders. The fire alarm system must be checked a stipulated frequencies. This will help to ensure effective fire safety for both people who live in the home and the staff team. An accredited trainer must now provide fire safety training. Training in relation to challenging behaviour should also be provided. This will ensure all staff are suitably trained to support individuals in a safe and consistent manner. Fir Lodge DS0000008180.V299252.R01.S.doc Version 5.2 Page 7 The planned environmental improvements should be completed. This would further improve the home for each individual. 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. Fir Lodge DS0000008180.V299252.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Fir Lodge DS0000008180.V299252.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 5. The quality in this outcome area is adequate. There is information available to assist people in making an informed choice of whether the service is suitable for them. Each individual is provided with their own guide to the service, which includes the home’s terms and conditions. Both of these documents should be updated. EVIDENCE: The home has both a Statement of Purpose and Service Users Guide. Whilst these documents provide comprehensive information the inspector found these to be out of date. Both documents still refer to New Era, which has recently become Dimensions (UK) Ltd and the National Care Standards Commission, which is now the Commission for Social Care Inspection. One individual’s Service User Guide examined contained three separate documents explaining how to complain and a copy of an inspection report dated December 2002. Fir Lodge DS0000008180.V299252.R01.S.doc Version 5.2 Page 10 Discussions with the manager confirmed that both documents are currently being reviewed and reprinted by the organisation. The new versions will be available shortly and an updated guide for people who use the service will be provided to each individual as soon as they are available. Any individual interested in the service would be subject to a comprehensive assessment process operated by the home. However, there have been no recent admissions to the home. Fir Lodge DS0000008180.V299252.R01.S.doc Version 5.2 Page 11 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 and 9. The quality in this outcome area is good. The care plans examined provided good information in how to support each individual. These are reviewed regularly. An experienced staff team provides appropriate levels of support to each person who lives in the home. Staff also advocate appropriately for individuals. The Risk Assessment process supports each person to take risks as part of an independent lifestyle. EVIDENCE: Three care plans were examined and these provided comprehensive information on the areas of support each person required. These records are contained in two separate files. The “Support Plan” contains the information staff would need to provide the appropriate care and support Fir Lodge DS0000008180.V299252.R01.S.doc Version 5.2 Page 12 for each individual on a day-to-day basis, for example morning/evening support needs. This file also contains records of each persons review meetings and risk assessments. The “Daily Notes” contain a record of relevant daily information, contact with health care professionals and any other correspondence sent/received. These daily records were well written, with only relevant information being recorded by staff. The home uses a pro-forma to ensure a clear record is maintained of the review/updating of each persons support plan. The manager told the inspector that although the home regularly reviews each support plan they have not been supported by a representative form the Funding Authority for approximately 18 months. The home is keen to develop a more person centred approach to the review process. Several staff have recently been trained as facilitators in this process. The inspector commends this development. The home continues to operate a key-working system through which each individual is allocated a named member of staff who plays a central role in coordinating the service they receive. Staff spoken with displayed a good understanding of their roles and responsibilities in this respect and it was apparent that this system works well within the home. Due to the nature of the disabilities of some of the people who live in the home it can be difficult for them to clearly communicate choices/wishes. Staff explained that they use a number of methods to ensure people are supported to make choices and decisions. For example staff use observation of body language, behaviours or gestures of individuals as indicators of choice/wishes as well as individuals being able to express themselves verbally or through sign language. There are both generic and person centred Risk Assessments in place. These support individuals to take risks as part of an independent lifestyle. These form part of each persons support plan and are regularly reviewed and updated. Fir Lodge DS0000008180.V299252.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17. The quality in this outcome area is good. Individuals are supported by staff to pursue activities which they enjoy, are tailored to their needs and which enable them to have an interesting and fulfilling lifestyle. Staff support each individual to participate in their local community and to develop their potential. Individuals are supported to enjoy holidays and visit families and friends. A healthy, balanced and varied diet is promoted. EVIDENCE: The home has a person centred approach in supporting each person to develop. The records maintained within the home enable each persons progress to be assessed and the support provided adapted accordingly. Fir Lodge DS0000008180.V299252.R01.S.doc Version 5.2 Page 14 Each person has his or her own timetable of activities. This includes regular access to local community facilities such as shops, cinema, pubs, social groups as well as Local Authority Day Services. On the day of inspection one individual returned from his day service where he had made some pottery. One individual who spoke with the inspector explained that he was going out that evening for a meal. He also showed photographs of a recent holiday to Spain and spoke of his trip on the Orient Express. Members of staff explained what individuals liked to do. It was apparent that they lead interesting and active lifestyles. Staff also use their key-working role to ensure each individual is supported to develop as much as possible. Key workers often suggest new ideas or places of interest. This approach led to the individual being supported in organising his trip on the Orient Express. Each person is encouraged to maintain contact with family and friends. One individual told the inspector he has a large family who regularly visit him in the home. They are always made welcome. Two relatives comment cards were returned to the Commission. They are complimentary towards the service provided by the home and the staff team. The menus show a wide range of food, which provide both a healthy and balanced diet. Whilst there is no formal menu planning as such, each person chooses what they would like to eat each day and this is respected. Fir Lodge DS0000008180.V299252.R01.S.doc Version 5.2 Page 15 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 and 20. The quality in this outcome area is good. The care plans clearly explain the support each individual requires in relation to their personal and health care. Experienced staff have a good knowledge of each individual’s needs and how to provide appropriate levels of support. An effective system of medication administration is in operation and this is well managed. EVIDENCE: The health needs of individuals are well met with evidence of good multi agency working taking place on a regular basis. All of those living at the home are registered with a general practitioner; there is evidence in care records to confirm that each person is supported with their primary healthcare needs such as optician and dentist. Fir Lodge DS0000008180.V299252.R01.S.doc Version 5.2 Page 16 Other specialist services are accessed when an identified need arises. These are provided by Bridges Community Learning Disability Team, such as specialists in challenging behaviour. Contact with each professional is recorded and forms part of each persons care plan. The care documentation in place for individuals provided clear guidance for staff on how they should support each individual with their personal care. Each “Support Plan” contains guidelines relating to physical needs, personal care, medication, continence, bathing and manual handling. Each individual also has a Health Action Plan, which hes been updated since the last inspection. This ensures that each person’s primary healthcare needs are monitored and any concerns are acted upon. These are supplemented by records of contact with each health care professional. Examination of these records showed they were accurately written and outcomes clearly recorded. There is a core of experienced staff who have a good knowledge of each individual’s healthcare needs. Any changes, which may cause staff concern, are noted and acted upon. It was evident at this inspection that the management and staff spoken with are sensitive to the personal/healthcare and emotional needs of those living in the home and through observation and discussion demonstrated respect to the wishes of individuals living at the home. The home uses the Boots Monitored Dosage System of medicine administration and this is well managed. Staff records examined show that staff have received training by Boots on this system and they also have in house instruction. The medication records include the organisations medication policy, profiles of medication and specimens of all staff signatures/initials. Two staff are required to sign medication records and this is consistently recorded. Fir Lodge DS0000008180.V299252.R01.S.doc Version 5.2 Page 17 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 and 23. The quality in this outcome area is adequate. Each individual is enabled to communicate their views and they can be confident that they will be listened to and their views acted on if necessary. Clear robust policies and procedures are in place in order to protect individuals who use the service from the likelihood of abuse, neglect and self-harm. The complaints procedure within the Service Users Guide requires amendment. The protection of individuals at the home would be improved if all staff are provided with training in managing challenging behaviour. EVIDENCE: There have been no complaints recorded since the last inspection. There are detailed policies and procedures in relation to concerns and complaints. Each individual has complaints procedures as part of their guide to the service however the home should review the need to include three different documents in the ‘service users guide’ relating to complaints. One document still refers to The National Care Standards Commission. This could be extremely confusing for individuals and the staff supporting them. The manager explained to the inspector that the complaints procedure for each individual needs to be amended/adapted further and this should be completed shortly. The comments earlier in this report to the Statement of Purpose and Service Users Guide refer. Fir Lodge DS0000008180.V299252.R01.S.doc Version 5.2 Page 18 Staff are provided with training in relation to the Protection of Vulnerable Adults and are subject to Criminal Record Bureau enhanced disclosures. Staff spoken with were clear on their responsibilities and what action they would take if they had any issues which caused them concern. They were also aware that they may need to advocate for some individuals who live in the home. Staff spoken with were clear about the advocacy role they have. Due to the vulnerability of some individuals, they would rely on staff raising concerns on their behalf. The two relatives comment cards received by the Commission confirmed that both families were aware of the home’s complaints procedure. Neither had made a complaint. Their comments were complimentary towards the service provided to their relative. The home accommodates individuals who have complex needs, some of whom present behaviour which challenges the service being provided. There are guidelines entitled “methods of approach” and associated risk assessments on personal files in relation to these behaviours. Although some staff have attended training in this area, others have not. All staff should be provided with challenging behaviour training to ensure they are equipped with the skills and abilities to support individuals who present such behaviours in a safe, effective and controlled way. The home notifies the CSCI promptly of any incidents affecting the wellbeing of any individual. All accidents/incidents are recorded and clear records are maintained in the home. The administration/storage of individual’s finances has been improved. These are now stored securely in the home’s safe which has a combination lock. Two individuals finances were checked during inspection and found to be securely stored, clear records maintained and all cash balances were correct. Fir Lodge DS0000008180.V299252.R01.S.doc Version 5.2 Page 19 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, 25, 29 and 30. The quality in this outcome area is adequate. Fir Lodge is homely, comfortable and appropriate environment to meet the diverse needs of the people who live in the home. The completion of the planned maintenance would improve the environment further. Each person is supported to individualise his or her bedroom. The home was clean, tidy and hygienic on the day of inspection. EVIDENCE: The home is a large Victorian house, set over three floors. It s situated within its own grounds which are accessible to wheelchair users. All communal areas of the home are well furnished and homely. The home benefits from a large dining area and separate lounge on the ground floor. Fir Lodge DS0000008180.V299252.R01.S.doc Version 5.2 Page 20 The kitchen has recently been refurbished and the cooker replaced. Several areas of the home have been redecorated. New carpets have been fitted in bedrooms and on the stairs/landing up to the first floor. All of this work has greatly improved the environment for the people who live in the home. The manager told the inspector that the remaining stair/landing carpets would also be replaced shortly. This is necessary as the existing carpets are worn and consideration should also be given to replacing the tiles in the toilet on the first floor, as these are old and some tiles, which have been replaced, do not match the existing colour scheme. The bathrooms and toilets on the ground and first floor were commented upon during the last inspection, with a requirement to make these more homely. Discussion with the manager confirmed this would be difficult due to the needs and abilities of the people living in the home. For example personal items or toiletries cannot be left in these rooms. In general toilets and bathrooms are tastefully decorated, clean and hygienic and therefore the requirement has been met. Two individuals showed the inspector their bedrooms. They were personalised and reflected individual tastes. Each person had many personal items and pictures/photos displayed. One individual accesses his bedroom by using a through floor lift. He was seen to use this independently and it was clear this greatly supports his independence in moving around the home. All areas of the home were cleaned to a good standard Fir Lodge DS0000008180.V299252.R01.S.doc Version 5.2 Page 21 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, 35 and 36. The quality in this outcome area is adequate. The relationships between staff and those living at Fir Lodge are well established. This provides a supportive environment for each individual who lives in the home. There is a strong core of committed staff working in the home. Staff are well supported by the manager. Staff are generally provided with appropriate training and support to ensure they can meet each individual’s care and support needs. Fire safety and challenging behaviour training must be provided to all staff. All staff are regularly supervised and appraised on an annual basis. EVIDENCE: Fir Lodge DS0000008180.V299252.R01.S.doc Version 5.2 Page 22 There is a core of well-established staff with varying abilities who are skilled and experienced to meet the needs of those living in the home. The manager told the inspector that there is a small turnover of staff but there is a current vacancy in the team. One new staff member was recently recruited but failed to arrive on the appointed start date. The home will now recruit again to fill this vacant post. Staff members spoken with were able to demonstrate a clear understanding of their role and responsibilities within the team and their own personal role and accountability. Discussions with staff members and observation of their work practice demonstrated that they were knowledgeable, communicated well and were comfortable with each individual living in the home. Individuals appeared happy and relaxed in the company of staff. Staff members spoken with told the inspector that the staff team was extremely open, honest and supportive. At times there have been issues within the team, similar to any other workplace. Staff however felt well supported by the manager and were able to discuss these issues in an open and honest way. These have always been resolved quickly and staff did not feel they affected the service provided to the people who live in the home. The training records of four staff were examined. Staff are provided with a variety of training opportunities. Training is provided either by the organisation or external training providers. Staff spoken with told the inspector that they are provided with both mandatory and additional training. One staff member told the inspector they had also completed their NVQ Level 3. Some issues regarding training remain. The issue of who is to provide fire safety training has now been resolved. This will now be delivered by an accredited external trainer, but is yet to be delivered to the staff team. Both examination of records and discussion with the manager and staff showed that there are, at times, significant levels of challenging behaviour to respond to. This can include environmental damage or actions which could cause physical harm to staff or the individual themselves. Some staff have received the relevant training in responding to these behaviours. It is essential that all staff are provided with training in this area to ensure they have the knowledge, skills and abilities to respond to challenging behaviour in a planned, effective and safe manner. Staff meetings are held, recorded and appropriate subjects are discussed in order to guide and direct staff practice. Staff members told the inspector they can agenda any item for discussion at these meetings and that they found them useful. These records show that since July 2005 there have been three meetings. Although these have been difficult to arrange due to staff shortages, Fir Lodge DS0000008180.V299252.R01.S.doc Version 5.2 Page 23 this is less than National Minimum Standards expects and the manager hopes to increase their frequency, as they are valued. Staff are provided with regular, formal supervision and appraised each year. Staff spoken with told the inspector they are supervised approximately every four to six weeks. One member of staff explained they were presently undergoing the annual appraisal process. All staff spoken with said they find both supervision and the appraisal process helpful and supportive. Fir Lodge DS0000008180.V299252.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 41, 42 and 43. The quality in this outcome area is adequate. The home is well managed ensuring that individual’s interests and rights are promoted and protected. The manager promotes a person centred approach and this is clearly communicated throughout the service. There are systems in place designed to promote and protect the health & safety of both individuals and staff. Minor improvements are required to ensure the welfare and safety of individuals and staff. The manager is competent to run Fir Lodge, and meet its statement of purpose, aims & objectives. The completion of NVQ Level 4/Registered Managers Award would support this process. Fir Lodge DS0000008180.V299252.R01.S.doc Version 5.2 Page 25 EVIDENCE: The manger Mrs Black has worked at the home for many years and has a very good understanding of the diverse range of needs of those living at the home. She is currently working towards completion of the NVQ Level 4 in Care/Registered Managers Award. She also undertakes periodic training to maintain her knowledge and update her skills and level of competence, recently completing her training to train others in facilitation of person centred planning. The management approach is open and positive, with a clear sense of direction and leadership. Staff spoken with spoke highly of the manager and the way that the home was run. They said they felt that she was approachable, they felt listened to and she set a good example and worked to support the people living in the home. The manager told the inspector she receives excellent support from her line manager. This helps to ensure she is supported to manage and develop the service for each individual who lives in the home. Her line manager also visits the home regularly and compiles a monthly audit report to comply with Regulation 26. The ethos of the service is described as being person centred. This is clearly promoted by both the manager and the organisation. There were examples of a person centred planning tool, a ‘path/pathway’. One had been used in relation to recruitment, training and development of staff and is prominently displayed in the office. In general, the recording systems in place to support the maintenance of health and safety in the home are being used consistently. Staff members have delegated responsibilities in relation to monitoring health and safety within the home. The fire logbook for the home was examined at this inspection. Regular fire drills are taking place; the last recorded dates were 23/05/06, 25/01/06 and 4/01/06. The alarm system, emergency lighting and fire extinguishers are serviced/checked annually. The fire officer last visited the home on 17/10/05. The fire alarm system should be checked on a weekly basis by staff. However, during the last sixteen weeks, there were minor gaps as there is no record of the fire alarm system being checked on three separate weeks. The use of an emergency chair that could be used to evacuate one individual in the event of a fire has been reviewed. This equipment is no longer used by the home. Fir Lodge DS0000008180.V299252.R01.S.doc Version 5.2 Page 26 The home maintains records relating to generic annual Health and Safety Inspections, COSHH products, PAT testing, lift servicing, electrical wiring, water temperatures and window restrictors. All of these records were in order and checks were up to date. Fir Lodge DS0000008180.V299252.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 25 26 27 28 29 30 3 3 X 3 X 3 3 X X X 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 STAFFING Standard No Score 31 3 32 3 33 3 34 X 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000008180.V299252.R01.S.doc 3 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Fir Lodge Score 3 3 3 X 3 3 3 X 3 2 3 Version 5.2 Page 28 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 YA1 Regulation 4,5,6 Sch 1 Requirement Ensure the Statement of Propose and each Service Users Guides are updated to comply with National Minimum Standards. Timescale for action 09/09/06 2. YA23 YA35 YA42 13(6)(7) 18(1)(c) 23(4) Ensure appropriate challenging behaviour training is provided for 09/12/06 all staff. The fire alarm system must be maintained in accordance with the Avon Fire Log guidance. Ensure appropriate fire safety training is provided for all staff. 3. 09/06/06 09/12/06 4. YA42 23(4)(d) 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. Fir Lodge Refer to Standard YA24 YA24 Good Practice Recommendations Replace the remaining stair/landing carpet and in the homes office. Retile the communal toilet on the first floor. DS0000008180.V299252.R01.S.doc Version 5.2 Page 29 3. YA20 Consider holding regular team meetings at frequencies which comply with National Minimum Standards. Fir Lodge DS0000008180.V299252.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 Fir Lodge DS0000008180.V299252.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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