Inspection on 22/06/05 for Flora Lodge

This inspection was carried out on 22nd June 2005.

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

Other inspections for this house

Flora Lodge 09/12/08

Flora Lodge 17/01/07

Flora Lodge 28/09/05

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 Leicester LE3 5QW Lead Inspector Chris Wroe Unannounced 22 June 2005 at 10.00am The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Flora Lodge C51 S45403 Flora Lodge V234702 220605.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Flora Lodge Address 21-23 Glenfield Road East Leicester Leicestershire LE3 5QW 0116 2530279 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Sudha Devi Rana Marika Halina Kozlowsky Care Home 15 Category(ies) of LD - Learning Disabilities - 5 registration, with number MD - Mental Disabilities - 15 of places Flora Lodge C51 S45403 Flora Lodge V234702 220605.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. No person falling within category LD may be admitted to the home unless that person also falls within category MD ie. Dual disability2. 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. Date of last inspection 18th January 2005 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. Flora Lodge C51 S45403 Flora Lodge V234702 220605.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place on a weekday, 22nd June 2005, starting at 10.30am and lasting for five and three-quarter hours. Six residents were spoken to during the inspection, and their views are included through the report. Comments made include: ‘The food is out of this world’. ‘The staff are very good. They listen to you.’ ‘ I get on with the others who live here’. ‘I’m staying here till I die’. Nine comments cards were received from service users. These gave mostly positive responses to questions about the home. One person wrote: ‘Since I have been here I have come on so well. All the staff are lovely, they all help me. The residents are ok sometimes.’ The main method of inspection used was ‘case tracking’, which involved selecting two clients and tracking the care they receive through checking records, talking with the clients and with care staff, looking round the home and observing care practices. What the service does well: There are good care plans in place in the home, which describe the social, and psychological needs of service users, as well as physical and medical needs. The health needs of service users are well met, and good systems for administration of medication are in place. Relationships between staff and service users are good. Attention is paid to maintaining service users’ rights. Service users are helped to find appropriate education, and access community facilities. The home has a complaints procedure and procedures for protection of vulnerable adults. Records generally are well maintained. The home has some very good policies in place, with a detailed policy file – it is clear a lot of attention has been paid to policy development. Ongoing safety tests are carried out relating to issues such as protection from fire, and water temperatures. The premises are clean and tidy and adequately furnished and fitted. Service users are able to bring their own personal possessions into the home. Flora Lodge C51 S45403 Flora Lodge V234702 220605.doc Version 1.40 Page 6 Relevant information about job applicants is collected to ensure staff working in the home are safe for service users. Staff receive training on an ongoing basis to ensure they are competent for the job they are doing. The manager is open and approachable, and service users felt able to raise any concerns with her. What has improved since the last inspection? What they could do better: Immediate action was required regarding two aspects: One service user was not able to shut his bedroom door, because of a structural fault, and so could not ensure privacy or security in his room. Before completion of the final inspection report, the manager advised that this had been rectified. One service user was concerned about lack of privacy due to an unlockable fire door between two bedrooms. This was also dealt with by the manager before the final inspection report was completed. Risk assessments were mainly in place but further detail is necessary regarding some aspects (identified confidentially with manager). Whilst policies and procedures are in place, training of the manager and staff in issues relating to protection of vulnerable adults from abuse must be carried out. Related to this, the manager must ensure proper reporting of serious incidents under Regulation 37 Care Homes Regulations 2001 and relevant guidance. Flora Lodge C51 S45403 Flora Lodge V234702 220605.doc Version 1.40 Page 7 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. Flora Lodge C51 S45403 Flora Lodge V234702 220605.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Flora Lodge C51 S45403 Flora Lodge V234702 220605.doc Version 1.40 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 standard(s) 2, 5 Full assessments of service users’ needs ensure that the home can provide proper care for them, promoting their welfare and well-being. Service users’ rights are protected by contracts of residence. EVIDENCE: Both social service department assessments and internal assessments were in place for service users, although in one case a key feature of risk relating to one service user had not been carried through to the care plan (see standard 9). Attention is paid in assessment to the social and psychological needs of service users, as well as physical and medical needs. Each service user has a contract in place detailing the terms and conditions of their residency in the home. Flora Lodge C51 S45403 Flora Lodge V234702 220605.doc Version 1.40 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 9 Service users benefit from clear care plans, which detail their individual needs and aspirations, and from assistance from staff in having control over their lives. Risk assessments mainly protect service users, although some gaps mean that promotion of their welfare cannot be fully guaranteed. EVIDENCE: Each service user has a care plan, which details their own care needs, and the things that are important for them. Care plans show that service users have been involved in their preparation. They are well written and show understanding of service users as individuals. Members of staff showed a good understanding of the needs of service users, which reflected care plans and what service users themselves said. Staff were observed interacting with service users and helping them to take control over aspects of their lives. There are procedures in place to help service users to manage their finances. Service users’ money is pooled in a single bank account, from which all monies are paid to service users regularly. The manager explained that a single account helps where some service users may not be able to get an account for themselves. It is recommended that the Flora Lodge C51 S45403 Flora Lodge V234702 220605.doc Version 1.40 Page 11 manager consult with service users, as appropriate, with reference to local banks, about their wishes to have an independent bank account. Good policies are in place in the home about risk assessment and managing areas of risk, for example, action to be taken if someone is absent from the home without explanation. Risk assessments were found to be in place regarding some aspects of care, but there were some gaps, where risks had been identified and/or describe by service users, but a risk assessment was not in place (specific aspects about vulnerability of service users discussed with manager). These areas need to be addressed and risk assessments put in place. Service users mostly said that they felt safe in the home. Flora Lodge C51 S45403 Flora Lodge V234702 220605.doc Version 1.40 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 14, 16 Opportunities for developing skills and participating in activities are provided, which benefit service users and promote their well-being. Service users’ rights to privacy and independence are considered and mostly promoted, although some shortfalls were noted. EVIDENCE: Some service users are going to college to learn new skills. Care plans showed that educational needs of service users are given attention. Of nine comments cards received, six described that there were enough activities provided. Three service users commented that there were not, but indicated they did not want to talk further about this with the inspector. Staff said that they tried to encourage service users to be involved in activities, and this was backed up in care plans and weekly contact records also. During the inspection, service users were seen to come and go from the home. The city centre and other amenities are close. Residents were talking with staff about a camping trip that was being planned. Flora Lodge C51 S45403 Flora Lodge V234702 220605.doc Version 1.40 Page 13 Staff were seen to be sensitive to service users’ privacy in entering bedrooms. Although service users have their own keys to their bedrooms, one service user was not able to shut his bedroom door properly because of a structural fault in the building, and so he was not able to keep his bedroom secure. The manager and owner were asked to rectify this immediately. There are four bedrooms in the home, which currently have fire doors between them which cannot be locked. This means that access is readily available from one room to the next. One service user was not happy about this situation, and the manager and owner were asked to rectify this immediately, to ensure that all service users felt safe and had privacy. Flora Lodge C51 S45403 Flora Lodge V234702 220605.doc Version 1.40 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20 Service users benefit from attention paid to health and medical needs and from access to local healthcare facilities. Service users are protected by good policies and procedures in administration of medication. EVIDENCE: Care plans show that attention is paid to the health needs of service users. During the inspection, the manager visited one service user who had been taken to hospital following a fall. Attention was paid to her emotional needs for support as well as physical health needs. Service users described that they have access to health care, such as local GPs and Community Psychiatric Nursing services. There are good policies in place in the home relating to administration of medication. Medication stores are kept secure and records reflect that medication is given out appropriately. Information kept on service users’ files includes details of medication and any side effects. Staff showed a good understanding of the needs of service users and of issues relating to medication, such as the need to monitor long-term use. Records show that reviews take place, with relevant health professionals involved. Only trained staff are involved in administering medication. Flora Lodge C51 S45403 Flora Lodge V234702 220605.doc Version 1.40 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22, 23 Service users’ rights are protected by a complaints procedure and the positive attitude of staff to hearing concerns raised. Service users benefit from staff attention to protecting them from harm, but shortfalls were identified in staff training and reporting, which mean that full protection from harm cannot be guaranteed. EVIDENCE: There is a complaints procedure in place in the home. Service users said that they felt they could approach staff or the manager to raise any concerns that they have, and that they will be listened to. Of comments cards received, eight out of nine service users said they felt safe in the home. One service user said that they felt safe ‘sometimes’. There are policies in the home relating to the protection of vulnerable adults from abuse, including the Department of Health Guidance, ‘No secrets’. The manager said that, while the policies were in place, neither she nor the staff had had training regarding protection from abuse. A relevant incident had recently arisen at the home, which had not been fully reported under the required procedures. The manager must ensure that she and staff are trained and fully aware of action, which must be taken in the event of any incident, and that proper reporting takes place. Flora Lodge C51 S45403 Flora Lodge V234702 220605.doc Version 1.40 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 26 Service users live in a clean and tidy environment, which promotes their wellbeing. Service users are able personalise their bedrooms and mostly have private access to their bedrooms, promoting their sense of identity and independence. EVIDENCE: All areas of the home seen were clean and tidy. There is a communal lounge for service users, and a dining room. Furniture is basic but sufficient. In the basement of the home, there is a room available to service users, where they may smoke. The home is in keeping wit the local community, and there is good access to bus services and local facilities. Service users’ bedrooms contain personal possessions as well as furnishings and fittings provided by the home. One service user showed a personal collection of miniature vehicles that they keep in their lockable cabinet. One service user raised a concern about his bedroom door, which he was unable to shut and lock, and immediate action was required by the home to rectify this (see previously, standard 16). Flora Lodge C51 S45403 Flora Lodge V234702 220605.doc Version 1.40 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34, 35 Staffing levels, robust recruitment procedures and staff training, ensure that service users are protected and their welfare promoted. EVIDENCE: Staff rotas showed sufficient numbers of staff on duty. Waking night staff are employed in the home, and the rota shows who is on call at all relevant times. Staff records showed that relevant documentation is collected in recruitment, such as Criminal Record Bureau checks and references. Very good information is provided to employees in a staff handbook, including code of conduct and employee rights. Certificates of training were contained in staff files, detailing courses attended by staff, including infection control, safe handling of medicines, and first aid. Service users said that they felt well supported and cared for by staff. Flora Lodge C51 S45403 Flora Lodge V234702 220605.doc Version 1.40 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39, 40, 41, 42 The open approach of the manager contributes to the well-being of service users. Policies, procedures and checks ensure that the safety of service users is protected. EVIDENCE: The manager described that she is open and approachable and this was seen during the inspection. Both service users and staff said that they felt able to talk her. One member of staff said that he felt very happy working in the home. It is recommended that the owners of the home carry out monthly visits, as specified under the Care Homes Regulations 2001, so that they can address any concerns that arise as soon as possible. There are extensive policies in the home, which set out working practices and procedures very clearly; examples include confidentiality, equal opportunities, whistleblowing and infection control. Records are kept in good condition and securely. Flora Lodge C51 S45403 Flora Lodge V234702 220605.doc Version 1.40 Page 19 Records of fire safety tests are in place in the home, and a fire risk assessment has been completed following an inspection by the fire service in December 2004. Accident records are in place. Water temperature checks are carried out at service users’ sinks and safe temperatures maintained. Flora Lodge C51 S45403 Flora Lodge V234702 220605.doc Version 1.40 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x 3 Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x 2 x x x x Standard No 11 12 13 14 15 16 17 x 3 x 3 x 2 x Standard No 31 32 33 34 35 36 Score x x 3 3 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Flora Lodge Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score x x 3 3 3 3 x C51 S45403 Flora Lodge V234702 220605.doc Version 1.40 Page 21 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 9 Regulation 13 Requirement Risk assessments must be drawn up for all aspects of risk identified in assessments/care plans or in daily living The provider must ensure that the bedroom door of the identified service user is repaired so that privacy and security can be ensured. The provider must take action to ensure that service users feel safe and have privacy in those bedrooms adjoined by unlockable fire doors. Training relating to protection of vulerable adults from abuse must be provided to the manager and staff. Reporting of serious incidents must be reported as required to the CSCI and other relevant agencies Timescale for action By 30th July 2005 Immediate - by 29th June 2005 Immediate - by 29th June 2005 By December 2005 By 30th July 2005 2. 16 16 3. 16 13 4. 23 18 5. 23 37 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Flora Lodge Refer to Good Practice Recommendations C51 S45403 Flora Lodge V234702 220605.doc Version 1.40 Page 22 1. Standard 39 In order that the provider maintains an up to date awareness of the running of the home and monitors all aspects to ensure outcomes for service users are met, it is recommended that the provider carries out monthly visits to the home in accordance with Regulation 26, Care Homes regulations 2001, and prepares reports of the visits, copies of which are provided to the Commission for Social Care Inspection. Flora Lodge C51 S45403 Flora Lodge V234702 220605.doc Version 1.40 Page 23 Commission for Social Care Inspection The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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 Flora Lodge C51 S45403 Flora Lodge V234702 220605.doc Version 1.40 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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. 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