Inspection on 08/08/05 for Hales Lodge

This inspection was carried out on 8th August 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

Hales Lodge 03/03/09

Hales Lodge 09/03/07

Hales Lodge 25/01/06

Hales Lodge 28/02/05

Hales Lodge 14/06/04

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

CARE HOME ADULTS 18-65 Hales Lodge Somerton Road Winterton On Sea Great Yarmouth Norfolk Lead Inspector Hilary Shephard Announced 8 August 2005 2.00pm th 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. Hales Lodge I55 s27468 haleslodge v236430 080805 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Hales Lodge Address Somerton Road, Winterton On Sea, Great Yarmouth, Norfolk, NR29 4AW 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) 01493 393271 01493 393271 Royal Mencap Society Mrs Beverley Jane Pitt Care Home 8 Category(ies) of Learning disability (8), Physical disability (8) registration, with number of places Hales Lodge I55 s27468 haleslodge v236430 080805 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: All service users have a learning disability; all or some may also have a physical disability Total number of service users not to exceed 8 Date of last inspection 28th February 2005 Brief Description of the Service: Hales Lodge is a purpose built care home providing care and accommodation for up to eight adults with learning and physical disabilities. The home is divided into two bungalows but all facilities are shared by service users. Specialist equipment is in place to ensure that service users are able to receive the most appropriate care. All service users have single accommodation and there is a good range of communal space. Hales Lodge I55 s27468 haleslodge v236430 080805 stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This routine announced inspection was carried out between 2 pm and 6.30 pm, during which time all residents and two members of staff were spoken with. Information in the report was gathered from residents, staff, the homes records, pre-inspection questionnaire and comment cards from three residents, one GP and four relatives. The inspector toured the building and looked at bedrooms, bathrooms and the lounges, and at the end of the inspection, feedback was give to the manager and deputy manager. What the service does well: 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. Hales Lodge I55 s27468 haleslodge v236430 080805 stage 4.doc Version 1.40 Page 6 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 Hales Lodge I55 s27468 haleslodge v236430 080805 stage 4.doc Version 1.40 Page 7 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 Residents needs are assessed before admission and residents are confident that the home is capable of meeting their needs. EVIDENCE: Files of two new residents were looked at and these contained comprehensive assessments of their needs. One resident advised she had chosen to live at the home as she felt it would best meet her needs. Residents advised that they visited the home before moving in to see if they liked it. Hales Lodge I55 s27468 haleslodge v236430 080805 stage 4.doc Version 1.40 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 and 9 Care plans are comprehensive and person centred providing clear guidelines enabling staff to understand and meet the residents’ needs. Risk assessments are lengthy and repetitive but address risks well. EVIDENCE: Two care plans were looked at. These contained a very good and informative section called “About me”, which included details about residents physical and emotional needs and how they like to be supported by the staff. Quite a few of the residents have difficulties with verbal communication and this is a valuable tool for staff to use when caring for the residents. All files contained risk assessments and although these were comprehensive and covered areas of risk, they were very lengthy, and repeated information previously recorded in care plans, and a recommendation has been made. Hales Lodge I55 s27468 haleslodge v236430 080805 stage 4.doc Version 1.40 Page 9 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) Not assessed at this inspection. EVIDENCE: Hales Lodge I55 s27468 haleslodge v236430 080805 stage 4.doc Version 1.40 Page 10 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 and 19 Staff are well aware of residents health needs, are good at monitoring them and acting upon changes, good support is provided as needed and in the way residents choose. EVIDENCE: Residents confirmed that staff were good at meeting their needs and they were happy to be in the home. Positive interaction was observed between staff and residents, and staff demonstrated a good understanding of individual residents needs. Many of the residents have limited verbal communication, and staff have learned to pick up non-verbal cues to allow them to give the appropriate care. Residents indicated in their comment cards that they felt well supported and were well cared for. Relatives comment cards indicated that they were all satisfied with the care provided. Meetings are held in the home every four months with the Learning Difficulties team and other healthcare professionals to review each residents care needs, and changes to care are made as needs dictate. Hales Lodge I55 s27468 haleslodge v236430 080805 stage 4.doc Version 1.40 Page 11 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) Not assessed at this inspection. EVIDENCE: Hales Lodge I55 s27468 haleslodge v236430 080805 stage 4.doc Version 1.40 Page 12 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, 27 and 29 The home is comfortable and equipment is provided which aims improve residents’ lives and promote independence. EVIDENCE: Improvements have been made to the décor, several bathrooms and toilets have been redecorated and a new bath has been installed. New equipment has been purchased to help residents’ comfort at night, to aid mobility and ensure safety in the bathroom. Residents all have individual armchairs and wheelchairs designed to assist with their specific disability, and one resident advised she had recently tried out a motorised wheelchair, which she hopes to obtain shortly. Hales Lodge I55 s27468 haleslodge v236430 080805 stage 4.doc Version 1.40 Page 13 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) 34 and 35 Residents are protected by new staff undergoing proper recruitment checks prior to commencement and by staff being specifically trained. EVIDENCE: The file of one new member of staff was checked. This contained two satisfactory written references and an enhanced CRB check, and identification. When interviewing staff the home uses a questionnaire and records the applicant’s answers, the applicant also has to undergo a written assessment, which demonstrates the home is thoroughly assessing prospective staff. Training records indicated that staff have undergone NVQ level 2 and some have completed level 3. Staff have attended a variety of training courses and sessions relating to caring for people with a disability. Three staff have recently completed training in communication. Hales Lodge I55 s27468 haleslodge v236430 080805 stage 4.doc Version 1.40 Page 14 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) Not assessed at this inspection. EVIDENCE: Hales Lodge I55 s27468 haleslodge v236430 080805 stage 4.doc Version 1.40 Page 15 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 x Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x 3 3 x 3 x Standard No 11 12 13 14 15 16 17 x x x x x x x Standard No 31 32 33 34 35 36 Score x x x 3 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Hales Lodge Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score x x x x x x x I55 s27468 haleslodge v236430 080805 stage 4.doc Version 1.40 Page 16 None 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 Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 9 Good Practice Recommendations The registered person is recommended to review all risk assessments to try and make them less repetitive and complicated. Hales Lodge I55 s27468 haleslodge v236430 080805 stage 4.doc Version 1.40 Page 17 Commission for Social Care Inspection 3rd Floor, Cavell House St Crispins Road Norwich NR3 1YF 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 Hales Lodge I55 s27468 haleslodge v236430 080805 stage 4.doc Version 1.40 Page 18 - 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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