Inspection on 17/01/07 for Flora Lodge

This inspection was carried out on 17th January 2007.

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

Flora Lodge 09/12/08

Flora Lodge 28/09/05

Flora Lodge 22/06/05

Flora Lodge 18/01/05

Flora Lodge 06/05/04

Flora Lodge 12/01/04

Similar services:

Hillside

Applegarth

Trevayler Residential Care Home

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

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

CARE HOME ADULTS 18-65 Flora Lodge 21-23 Glenfield Road East Leicester Leicestershire LE3 5QW Lead Inspector Rehana Rashid Key Unannounced Inspection 17th January 2007 09:45 Flora Lodge DS0000045403.V323210.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 Flora Lodge DS0000045403.V323210.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. Flora Lodge DS0000045403.V323210.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Flora Lodge Address 21-23 Glenfield Road East Leicester Leicestershire LE3 5QW 0116 2530279 0116 2291298 flora-lodge@hotmail.com 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) Sudha Devi Rana Harbansh Rana Marika Halina Kozlowsky Care Home 14 Category(ies) of Learning disability (5), Mental disorder, registration, with number excluding learning disability or dementia (14) of places Flora Lodge DS0000045403.V323210.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. To be able to continue care for the named person of category MD(E) named in Variation V23781 application dated 5 August 2005 Service User Numbers No person falling within category LD may be admitted to the home unless that person also falls within category MD ie Dual disability. Service User Numbers No person falling within categories MD/LD may be admitted to the home when 5 persons falling within categories MD/LD are already accommodated within the home. 28th September 2005 Date of last inspection Brief Description of the Service: Flora Lodge is a residential care home for up to fourteen people who experience mental ill health. Care can also be provided for up to five service users who have a learning disability also. The home is situated close to the city centre, located on a main road with bus links into the city. Shops, pubs and other amenities are situated within walking distance of the home. The rooms in the home are spread over four floors, which are accessed by stairs there are no lifts in the home. There are ten single bedrooms and two shared rooms, one of which is currently used as a single bedroom. There is also a communal dining room and lounge, and a basement room for service users to smoke in. At inspection on 17th January 2007 the Registered Manager stated that the current weekly fee range is between £279 to £317. In addition to the weekly fee there are additional charges for hairdressing. Information about the service available is provided in the statement of purpose. Flora Lodge DS0000045403.V323210.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was carried out on 17th January 2007 for the duration of five hours. The main method of inspection was case tracking, which involved examining care records for two residents. Case tracking is used to establish if the needs of the residents are being appropriately assessed by the home and their needs are being catered for. Indirect and direct observation of practice and interaction between staff and the resident was also carried out as part of the inspection methodology. The communal areas, shower room, bathroom, kitchen, two bedrooms and garden were viewed during this site visit. Other documentation including health and safety records were also examined. Prior to completing the inspection visit the inspector assessed the preinspection document completed by the registered manager. The Registered Manager and Registered Provider assisted in the inspection process. Two residents and two members of staff were spoken to as part of the inspection. During the course of the inspection some residents were out to day care and others were at home. Residents spoken with stated they enjoyed living at the home and the staff were kind to them. They also stated staff knocked on their doors prior to entering. The staff members on duty spoke with residents in a respectful and sensitive manner. Two residents spoken with stated they are aware of the complaints process but have had no reason to make a complaint. The focus of the inspection was to concentrate on the key standards, which were assessed under the new methodology of Inspecting for Better Lives (IBL). What the service does well: Flora Lodge Care Home provides its residents with a welcoming and homely environment. The registered manager and staff encourage residents to be as independent as possible. During the inspection staff were observed to positively interact with residents and spoke with them respectfully. The quality of care and support for residents is good. Flora Lodge DS0000045403.V323210.R01.S.doc Version 5.2 Page 6 Residents were very pleased with the care received. Residents presented as relaxed and happy and there was lots of conversation and laughing between residents and the staff. Residents were well groomed. Activities for residents are well organised suiting individual needs. Residents are able to maintain links with family and friends. They are able to visit relatives and have visitors to the home. Care plans provide details of resident’s social and psychological needs. The homes filing system is well organised, ensuring documentation is easily accessible. 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. The summary of this inspection report can be made available in other formats on request. Flora Lodge DS0000045403.V323210.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Flora Lodge DS0000045403.V323210.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2,4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents individual aspirations and needs are assessed prior to moving to the home. EVIDENCE: Prospective residents needs are assessed prior to moving into Flora Lodge Care Home, ensuring the home are able to meet the residents needs. Files viewed contained extensive community care assessments from Social Services. The admission criteria was clear and the procedure for admission gave residents opportunity to visit the home and meet staff prior to moving in. The registered manager stated prospective residents are encouraged to have overnight stays to ensure that Flora Lodge Care Home is the right environment for them. Flora Lodge DS0000045403.V323210.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual care plans reflect resident’s needs and how needs will be met. Staff encourage residents to make own decisions about their lives with assistance as needed and to take acceptable risks as part of promoting independence. EVIDENCE: Two residents support plans were viewed during this inspection. Files viewed were well organised containing significant information regarding the individual needs of the residents. Care plans were comprehensive and clear about the level of assistance each resident requires. One staff member spoken with stated that care plans are discussed with the residents. The staff member commented that staff work towards enhancing residents independence. Staff spoken with demonstrated a good understanding of the needs of the residents. Records seen evidenced that care plans and risks assessments are reviewed regularly. Risks assessments are completed in area’s regarding individual risk. One of the residents case tracked risk assessments was detailed, as to what action staff would need to take to minimise the identified risk. Another Flora Lodge DS0000045403.V323210.R01.S.doc Version 5.2 Page 10 resident’s assessment identified a potential area of risk, however there were no details of actions to be taken in place regarding the identified risk. Risk assessments should be detailed as to what action staff would need to take to minimise any identified risk. Residents spoken with commented that they are able to do as much as they can to maintain independent. The home operates a key worker system. On the day of the inspection residents were observed to come and go from the home as they pleased. Throughout the inspection staff were observed with residents assisting them to participate in day-to-day living. Flora Lodge DS0000045403.V323210.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Residents are given opportunities for personal development and are able to participate in appropriate activities. Residents at Flora Lodge Care Home are encouraged to maintain appropriate relationships with family and friends. The home is committed to respecting resident’s rights. Residents are provided with a healthy and varied diet. EVIDENCE: On the day of the inspection some residents were out to day care whilst other residents were at the home. Two of the residents files viewed contained details of social activities they undertook. Residents spoken with stated that the home arranges outings, which include going to the local pub and Skegness. One resident stated he enjoyed attending Church service at a local church. Two residents spoken with stated that there were enough activities provided. One resident spoken with stated he keeps contact with his family and they are able to visit when they like. Throughout the inspection residents were seen to come and go from the home. Flora Lodge DS0000045403.V323210.R01.S.doc Version 5.2 Page 12 The registered manager knocked on resident’s bedroom doors prior to entering ensuring residents privacy was respected. Residents spoken with confirmed this staff practice. Residnets stated they have keys to their bedrooms. Resident spoken with indicated that meals are varied and wholesome and Choices are available. The residents comments about meals included ‘meals are good’ and “there is plenty to eat.” The Registered Manager stated the menu is planned in consultation with the residents. The residents spoken with confirmed they are involved in the planning of meals stating they are able to decide what they wish to eat. Staff knew about the likes and dislikes of the residents. The food storage was clean and there was a selection of foods including fresh vegetables and fruit. Records are maintained of meals taken within the home. Flora Lodge DS0000045403.V323210.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ personal and health care needs were met with support and assistance from staff and other health and social care professionals. The arrangements for the administration, storage and recording of medicines in the home needs are appropriate. EVIDENCE: Two resident’s files viewed at this inspection contained details of their personal and health care needs, which were clearly documented. Daily communications sheets and care plans confirmed residents receive input from health care professionals when required including the GP. Care plans contained details of other professionals involved in resident’s care including Social workers, Community Psychiatric Nurses and Psychiatrist. Staff spoken with were aware of individual health care needs and preferences. Residents spoke positively about the quality of care provided by the staff. Medication was observed to be stored securely in a lockable cupboard. Flora Lodge use a monitored dosage system for the majority of the medicines. The home has policies and procedures in place with regard to administration and storage of medication. Information is kept on the resident’s files stating details of current medication being taken. The registered manager stated staff administering medication have been trained. Flora Lodge DS0000045403.V323210.R01.S.doc Version 5.2 Page 14 The Medical Administration Records were found to be well organised in the file and there was no gaps in the entries for the two residents case tracked. Flora Lodge DS0000045403.V323210.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is an appropriate complaints procedure in place and service users feel they are listened to. Written policies and procedures in relation to safeguarding vulnerable adults protect residents from potential harm; there are shortfalls with training for staff in abuse. EVIDENCE: There is a complaints procedure in place at the home. Residents spoken with on this inspection were happy with the home and how they could always talk with staff. They felt listened to and confident that the manager and staff would try to sort things out. The complaints book was viewed which keeps records of complaints, both complaints documented had been resolved. No adult protection investigations have taken place during the last twelve months. Procedures where in place, in relation to adult protection. A copy of the Multi-Agency Policy and Procedures for the Protection of Vulnerable Adults from Abuse was in place. Staff members spoken with demonstrated that they had an understanding of the whistle blowing procedure. Staff spoken with commented that they had not received training regarding protection of vulnerable adults. Flora Lodge DS0000045403.V323210.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment within this home is good and provides residents with a homely place to live. The home is clean and hygienic. EVIDENCE: Flora Lodge Care Home offers its residents a clean and well-maintained environment. There is a garden located at the rear of the property. Inspection of bathrooms, bedrooms and communal areas such as the living room and dining room were found to be suitable for residents. Bedrooms viewed were personalised with televisions, ornaments, stereos and photographs. Communal rooms were comfortable, homely and spacious. The residents spoken with commented that they liked the new carpet in the lounge. Residents spoken with commented that they liked the home. The atmosphere around the home was friendly and relaxing. On the day of the inspection the home was free from mal-odour. The overall standard of cleanliness in home was good. The laundry area was well organised. Following the last inspection a new industrial dryer has been purchased. New flooring has been fitted, which was reported to be easier to Flora Lodge DS0000045403.V323210.R01.S.doc Version 5.2 Page 17 clean. There is one washing machine in the home, which the registered manager stated is able to wash at high temperatures Flora Lodge DS0000045403.V323210.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported by competent and qualified staff that are trained. The homes recruitment policy and procedure needs to be robust to ensure it protects residents. EVIDENCE: The staff rota was viewed, which was found to be an accurate record of who was on duty on the day of the inspection. One waking night staff member is on duty at night. Two staff files were viewed and provided evidence of adequate recruitment and selection process, including application forms, interview notes and satisfactory criminal records bureau checks. Both staff files did not contain all items as listed in schedule 2 and schedule 4 of the Care Homes Regulation 2001, including items such as proof of identification. Training is available for staff to ensure they develop in their roles and meet the needs of the residents. Staff spoken with confirmed that they have received training, which includes food hygiene. Staff spoken with commented that the training provided is good. Certificates of training viewed detailed courses attended by staff safe handling of medication and fire awareness. The registered manager stated four members of staff have successfully completed National Vocational Qualification level two. Flora Lodge DS0000045403.V323210.R01.S.doc Version 5.2 Page 19 Staff were friendly and welcoming to the inspector and had positive relationships with the residents, demonstrating a caring attitude. Staff spoken with demonstrated a good understanding of the needs of the residents. One staff member stated some of the staff had been working at the home for a number of years and have a very good understanding of individual resident needs, which is very helpful when new staff start. Flora Lodge DS0000045403.V323210.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This is a well managed home, that benefits from formal quality assurance and quality monitoring systems. EVIDENCE: The registered manager was present throughout the inspection and demonstrated good management knowledge. She has worked at Flora Lodge for a number of years. Staff spoken with stated the registered manager is very supportive and approachable. She is currently in the process of completing National Vocational Qualifications Level 4. Staff and residents commented positively about the leadership style of the manager. Files were kept in good order and easily accessible for inspection. Residents at Flora Lodge participate in residents meeting, where issues are raised and suggestions are made. The registered manager stated that the quality assurance system adopted by Flora Lodge takes place annually. Questionnaires are distributed to residents. Flora Lodge DS0000045403.V323210.R01.S.doc Version 5.2 Page 21 Two questionnaires were seen from the last quality assurance audit, which took place 2006, overall the feedback was positive about the care and services provided. The registered manager stated that the registered provider has been carrying out monthly visits, so that any concerns can be addressed as soon as they arise. The inspector was unable to view the report has they were stored on the computer system which the registered manager was unable to access. Prior to the site visit the registered manager completed the Pre-Inspection Questionnaire and provided details of maintenance and associated records. A range of records relating to health and safety were examined. Records of fire system tests, and portable appliances testing were observed and found to be carried out at the required intervals. A valid employers liability insurance certificate was displayed in the entrance hall. During the partial tour of the building one window on the first floor was noted to be wide open with no window restrictor. One bathroom window also did not have a restrictor fitted. Due to the potential vulnerability of the service users the registered person should ensure that risk assessments are carried out in relation to any windows in the home, which do not have restrictors fitted and that safety measures are put in place where a need is identified. Flora Lodge DS0000045403.V323210.R01.S.doc Version 5.2 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 Standard No Score 1 X 2 3 3 X 4 3 5 X 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 3 25 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 X Flora Lodge DS0000045403.V323210.R01.S.doc Version 5.2 Page 23 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA23 Regulation 18 Requirement Timescale for action 31/07/07 2. YA34 7,9,17,19 The registered person must ensure training relating to protection of vulnerable adults from abuse be provided to all staff. Recruitment procedures to be 30/04/07 more robust, the registered person to ensure all staff files to contain all items as listed in schedule 2 and Schedule 4 of the care homes regulation 2001. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA9 YA42 Good Practice Recommendations The registered person should ensure all risk assessments are detailed and action to be taken to minimise any identified risks. The registered person should carry out risk assessments in relation to any windows in the home, which do not have restrictors fitted and that safety measures are put in place where a need is identified. Flora Lodge DS0000045403.V323210.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Flora Lodge DS0000045403.V323210.R01.S.doc Version 5.2 Page 25 - 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!