Inspection on 23/06/05 for Harefield Lodge

This inspection was carried out on 23rd June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Harefield Lodge 03/10/06

Harefield Lodge 08/11/05

Harefield Lodge 01/12/04

Harefield Lodge 30/07/04

Harefield Lodge 08/10/03

Harefield Lodge 03/06/03

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

CARE HOME ADULTS 18-65 Harefield Lodge 6 Westwood Road Southampton Hampshire SO17 1DN Lead Inspector Chris Hemmens Unannounced 23rd June 2005 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. Harefield Lodge H55-H03 S11916 Harefield Lodge V218907 100505.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Harefield Lodge Address 6 Westwood Road, Southampton, Hampshire, SO17 1DN 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) 023 8055 5802 Rivers Reach Care Limited Sonia Beverley Osborne Care Home 10 Category(ies) of LD - 10 registration, with number of places Harefield Lodge H55-H03 S11916 Harefield Lodge V218907 100505.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 01/12/04 Brief Description of the Service: Harefield Lodge provides care and support for up to 10 younger adults with learning disability and challenging behaviour. The home’s aims and objectives are to promote independence and quality of life by ensuring service users are able to be involved in all aspects of daily living and personal care. Help is given when required but service users are supported to live their lives as independently as possible. Harefield Lodge is part of the Rivers Reach Care Limited who also own a further three homes providing care and support for service users with learning disabilities and complex needs. Harefield Lodge is a large family house situated in a quiet residential road of Portswood. It is close to local amenities and Southampton Common is within walking distance. Accommodation is provided in single rooms over two floors. One room has its own ensuite and separate lounge area. There is a lounge and separate dining room and a spacious enclosed garden. Harefield Lodge H55-H03 S11916 Harefield Lodge V218907 100505.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first unannounced visit to the home this year; the visit was carried out over one day with the support of the registered manager, residents and staff. The purpose of the visit was to review the twenty-two requirements issued at the previous inspection. The home has demonstrated a very good commitment to meeting the twenty-two requirements issued following the previous inspection one requirement was repeated. Six requirements were issued in total following this visit. As part of the visit the inspector met and spoke with residents and staff, viewed residents personal records and took a tour of the building. At the time of the visit the home was very busy supporting residents to undertake various activities in the home and in the community. What the service does well: The home does well to provide an environment that meets the assessed health and welfare needs of the residents, including their individual wishes and goals. The home attempts to use person centred approach in encouraging and supporting residents to make decisions and choices about their daily and future lives. The home is well run by a manager who has very good leadership skills and supports the residents and staff to achieve their goals. The staff demonstrate good values and respect towards the needs of the residents, they are well trained and appear skilled and competent. Good relationships have been developed between residents and staff. One resident informed the inspector “I like living at Harefield Lodge because the staff are very kind and always listen to me”. The home does well to provide a home that is very clean, and in general well decorated and furnished. Each resident has a room of their own which they demonstrated on the day of the visit that they are very proud of. The home provides as far as feasibly possible a safe environment for residents to live, thorough recruitment checks and safe systems for holding and checking residents finances are in place and staff demonstrated they are aware of their roles and responsibilities in ensuring residents are safeguarded against abuse. Regular health and safety and fire checks are undertaken on the home and the majority of the home appliances have been serviced and certificated. Harefield Lodge H55-H03 S11916 Harefield Lodge V218907 100505.doc Version 1.30 Page 6 The home demonstrates that it is creative and keen to take on new ideas. Very good work has been done in developing a guidance pack for staff in the safe administration of medication and the member of staff concerned is commended for this piece of work. Another member of staff showed commitment to developing the developing and encouraging residents to explore new activities and hobbies using a person centred approach. What has improved since the last inspection? What they could do better: The home has been issued with six requirements on this occasion, which demonstrate the areas the home could improve on. The home is open and inclusive and supports residents to make choices about their everyday lives, however, the home needs to take this a step further in ensuring residents are addressed by the name they wish to be known by and by attempting to empower the residents to take ownership of their personal plans and develop plans that are significant and real for the resident. This includes supporting residents with limited communication and cognitive abilities to understand their plans and know how to complain if they are unhappy. The home could do better to improve the bathrooms, providing a more homely and inviting environment for residents to relax and enjoy their baths, in addition to assist the eradication of unpleasant odours on the entering the home. The manager is advised to replace the flooring in the downstairs toilet. To ensure the home is as safe as feasibly possible the home must ensure all potable electrical appliances including residents’ personal items are fully and regularly serviced. Harefield Lodge H55-H03 S11916 Harefield Lodge V218907 100505.doc Version 1.30 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. Harefield Lodge H55-H03 S11916 Harefield Lodge V218907 100505.doc Version 1.30 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 Harefield Lodge H55-H03 S11916 Harefield Lodge V218907 100505.doc Version 1.30 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) 3 The home does well to reassess and make good judgements if they can meet the needs of residents who are already resident within the home. EVIDENCE: This is evidence by the written letters of consultation with health care professionals and discussion with the Commission for Social Care Inspection when a resident became seriously unwell and was admitted to hospital. The registered manager attended the hospital prior to discharge to reassess the resident’s needs and had to make the very difficult decision not to accept the resident back as the specific care and support had become nursing. The home is not registered for nursing and the staff are not fully trained or equipped to meet the specific nursing care the resident required. Harefield Lodge H55-H03 S11916 Harefield Lodge V218907 100505.doc Version 1.30 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 and 9 The home continues to make improvements in the areas of person centred planning, involving residents in making decisions and risk taking. However further work is required to ensure the residents plans are produced in a format that is accessible for them and empowers them to have ownership. EVIDENCE: Harefield Lodge H55-H03 S11916 Harefield Lodge V218907 100505.doc Version 1.30 Page 11 The inspector viewed two residents’ personal plans with the residents. These included the residents’ personal details such as their Date of Birth, and contact details of the residents’ next of kin, GP, and Social Worker In addition good practice was seen in the development of personal profiles/pen pictures of the resident, assistance required for carrying out everyday activities such as personal hygiene and how this is achieved, a list of likes and dislikes, behaviours that challenge, areas of risk, relationships and their finances. There is evidence of good practice of the manager regularly reviewing the plans and the residents signing in agreement. However through discussion it was established that an area of care for one resident hadn’t been changed in the plan following the monthly review. The manager is advised to change the plans as soon as possible after the monthly review to ensure the residents’ needs are being met appropriately and consistently. At the previous visit the inspector was informed that the home was working towards producing the plans in an accessible format for the residents, however to date this has not been achieved. This was demonstrated when the inspector met with two residents who talked the inspector through their personal plans, one resident had the ability to understand the written word and confidently spoke about the her plans, however another resident demonstrated that he had limited understanding of the written word and showed signs of becoming frustrated that he could not understand what had been written about him. The home supports residents varying degrees of cognitive ability and therefore the manager is required to develop the person centred plans, using an individual approach that will assist in empowering the residents to have ownership and a better understanding of their plans. The inspector saw evidence of residents being involved in making decisions and choices about everyday aspects of their lives, including meals, activities and risk taking. The home has produced a very good menu plan that is accessible for the residents, residents are encouraged to choose from a range of meals that have been photographed and laminated into a file. All staff with whom the inspector spoke with said they had enjoyed putting the menu plan together with the residents and found it very beneficial for the residents in making choices. The inspector viewed a small number of risk assessments for two residents’ these clearly detailed the identified individual risk to the resident, and in the majority of those seen, how staff must support the service users to minimise the risks. However this was not found in all risk assessments and the manager is advised that she must ensure that all risk assessments describe how the resident is to be supported. There was good practice seen that risk assessments are reviewed monthly and signed by staff that they have read and understood them. This was further evidenced when the inspector spoke with staff and they could reflect what was in individual plans and risk assessments. The inspector observed staff following care plans and risk assessments in detail when enquiring with a resident in general conversation their whereabouts. The home works in conjunction with the specialist health care teams in formulating risk assessments when required. Harefield Lodge H55-H03 S11916 Harefield Lodge V218907 100505.doc Version 1.30 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) 12,13, 15,16 and 17 The home provides an active and stimulating environment for residents to live, where staff respect and support residents to achieve their goals, wishes and desires, be part of their local community, maintain relationships and enjoy a healthy eating lifestyle. However the home must ensure staff are aware of the name the resident wishes to be known by. EVIDENCE: On the day of the visit all residents were attending day service activities, supported employment or being supported by staff to engage in activities of the residents choice. The inspector was informed that a designated member of staff has been nominated to review all activities for the residents and meet individually with each resident to establish their personal goals and dreams in terms of activity. The manager stated she had appointed the member of staff to undertake this role following reading the “valuing people” white paper. The same member of staff has been trained to use a sensory room in order that she can support a resident with limited communication and cognitive ability to access this facility. The inspector had a long discussion with the member of staff who appeared very enthused with her new role as activity coordinator. Harefield Lodge H55-H03 S11916 Harefield Lodge V218907 100505.doc Version 1.30 Page 13 Each resident’s activity plan details the activities the residents enjoy participating in and the support and resources required to undertake the activity. Evidence was seen of how staff have encouraged residents to increase their activity and especially how the staff worked with the resident to explore what they liked and didn’t like. For one resident there is evidence of their social needs changing significantly, preventing him from participating in social and community activity. However the home attempts to support and stimulate him by providing him with an activity he really enjoys. The manager expressed her concerns regarding the residents and her attempts to involve Social Services to call a review of his needs. One resident informed the inspector that she really enjoyed living at Harefield lodge because she got to do lots of things she likes doing, such as horse riding and attending cooking classes at college and that she was really looking forward to going on holiday. Each resident enjoys at least one seven-day holiday a year. On the day of the visit residents were observed making decisions about what they wanted to do and staff providing advice and support in respect of their decisions. One resident did not wish to attend work, staff were observed using gentle persuasion and informed choices to encourage the resident to go, this is in line with the guidance provided in the residents notes. There is evidence that residents are supported to maintain family links and friendships inside and outside of the home. However where concerns have been raised regarding specific relationships and the vulnerability of the residents there is documentary evidence to support this, with guidance in place for staff. One resident is regularly supported to visit her family, the resident is supported to choose the day she wishes to go and staff will try and arrange the visit. This process demonstrates that staff are aware of the importance of inclusion and empowerment and respect residents choices and decisions and where possible support them to carry out what they wish to do. However the requirement issued following the previous visit to record in the residents plan the name they wish to be known by has not been met and will be carried over. The inspector observed a very good piece of work where staff have produced a picture menu plan for the residents, residents were observed making choices from the plan. The inspector was informed that both the residents and staff enjoyed putting the plan together and found it beneficial for all. The staff are aware of the importance of providing a well balanced diet and recording what the residents have eaten or any changing dietary needs. The home seeks advice from the GP or dietician if they are concerned about resident’s diets or eating habits. Harefield Lodge H55-H03 S11916 Harefield Lodge V218907 100505.doc Version 1.30 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) 18,19 and 20. The home demonstrates good practice in supporting residents with their personal, physical, emotional and health care needs. Very good work has been done in developing a medication guidance pack for staff. EVIDENCE: The inspector saw evidence in residents’ personal plans that the home takes seriously the health care needs of the residents. The manager keeps very good records of discussions and the outcome of those discussions she has had with health care professionals. In addition the manager has a system where she is notified of any serious concerns and occurrences relating the health and wellbeing of the residents. This is seen as very good practice. The inspector was informed of a recent situation with one resident who had deteriorated over a number of months, where his condition was causing her great concern. The manager demonstrated that she had done everything in her power to ensure the resident received the right medical care and eventually surgical intervention. The resident is now making a slow but good recovery and the home continues to monitor his progress. The home is well supported by the specialist health care team who have worked closely with a number of the residents living in the home. Assessments have been carried out on residents following reviews and incidents that have caused concern. The requirement issued following the previous visit to the home to carry out moving and handling assessments on all residents has in part been met. The Harefield Lodge H55-H03 S11916 Harefield Lodge V218907 100505.doc Version 1.30 Page 15 manager has carried out moving and handling assessments on those residents who require support, the assessments include using the stairs, accessing the garden and slips, trips and falls. The manager is advised to assess all residents to ensure they do not need physical assistance getting around and look at the residents moving and handling needs using the bath, getting in and out of vehicles and in and out of chairs. If staff are providing any form of support including just touch support then a risk management plan is required. The manager informed the inspector that nine staff have received training in moving and handling. The inspector did not fully review the medication procedures, however the inspector was shown a very good piece of work undertaken by a senior member of staff on medication. The senior had been given the objective to put together an information pack on the procedures and medications used in the home. The member of staff confidently talked the inspector through the information pack that was clearly laid out and recorded in plain English. The pack has been developed into sections and includes information on medication order history, (repeat prescriptions), policies and procedures relating to the system used in the home, ordering, administration, storing, disposal and reviews. Acts, guidance and legislation. The member of staff is commended for this piece of work. Staff are currently undertaking training, using a training pack specifically designed for care homes in the safe handling of medication. The training pack includes administration, including liquids, the use of Monitored Dossett Systems, and taking verbal orders form GPs etc. An outside assessor monitors staffs’ work and the first exam is due in August 2005. Harefield Lodge H55-H03 S11916 Harefield Lodge V218907 100505.doc Version 1.30 Page 16 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 and 23 The home provides an environment where residents as far as feasibly possible are safeguarded against abuse and are supported to make complaints, however the home must ensure residents can access the complaints procedure. EVIDENCE: The manager has recently revised the homes complaints procedure, which is clearly laid out in large print and stated how the resident can make a complaint and who they can speak to. However the written format does not meet all the residents’ communication and cognitive abilities and therefore the manager is required to develop a complaints procedure that meets the residents’ individual needs. The inspector met with two residents who stated they did not have any complaints about the home, the staff or the facilities. One resident said she really liked living at Harefield and “the staff are very nice and they listen to me”. The resident knew whom she could speak to if she were unhappy or had any concerns. As far as feasibly possible the home safeguards residents from abuse. Eight of the nine staff working in the home have received training in abuse awareness and the manager is hoping to do a “Train the Trainer” course in abuse awareness. Staff with whom the inspector spoke with were very clear of what they considered abuse and what they would do in the event of witnessing or an alleged abuse had been reported to them. This is a significant improvement in the last year for this home as previously their had been concerns that the home was not following robust procedures. Discussion took place with regards to a complex situation that has arisen in the home where a resident has placed them self at risk of abuse. A lengthy discussion took place with regards to the home’s duty of care versus the individual rights. The situation is in hand and will be subject to further Harefield Lodge H55-H03 S11916 Harefield Lodge V218907 100505.doc Version 1.30 Page 17 discussion in a forthcoming strategy meeting. In the meantime the procedures in the home provide clear guidance for staff in supporting the resident. The guidance was observed in practice at the time of the visit. Following the previous visit to the home, the home was required to notify the Commission for Social Care Inspection on how the residents monies were being managed, especially those where the organisation is appointee. The inspector was provided with evidence that the residents have their own bank accounts and there is a safe audit system for tracking residents’ expenditure and balances. Harefield Lodge H55-H03 S11916 Harefield Lodge V218907 100505.doc Version 1.30 Page 18 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, 25, 27 and 30. The home provides a warm and welcoming environment for residents to live, however further aesthetic improvements are required for the bathrooms and a change of floor covering in a toilet. EVIDENCE: Harefield Lodge H55-H03 S11916 Harefield Lodge V218907 100505.doc Version 1.30 Page 19 Harefield Lodge is a large period property situated close to the centre of Southampton. The home boasts some attractive period features and all the rooms accessed by the residents are spacious, bright, and pleasantly decorated and furnished. The home is kept very clean and tidy and where possible free from offensive odours. The manager has done her utmost to try and eradicate the unpleasant odour from the downstairs toilet. The manager is advised to replace the flooring in this area. The manager has added some soft furnishings to improve the aesthetic appearance of the bathrooms, however it was identified at the time of the visit the bathrooms could do with redecoration. The home has a large enclosed garden that has undergone extensive renovation work. The work included building a large decked area, landscaping the green and building an enclosed pond and nature area. A small area of the garden has been identified as an area that a resident can use as his own to plant and dig over as much as he wants. All bedrooms viewed by the inspector were found to be clean, spacious, pleasantly decorated and furnished to reflect the service users’ hobbies, interests and character. One resident took great pride in showing the inspector his room and another stated she really liked her room. Residents can have a key to their room if they wish. Following the previous visit to the home the manager was required to expand the procedures on infection control and provide evidence that the installation of homes washing machine meets the 1999 Water Regulations Act. The manager provided evidence that both requirements had been achieved. The inspector saw evidence of risk assessments for both residents and staff in transporting soiled laundry and a certificate from the water board stating the homes washing machine has been installed as per the regulations. Harefield Lodge H55-H03 S11916 Harefield Lodge V218907 100505.doc Version 1.30 Page 20 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, 35 and 36 The home undertakes robust recruitment procedures to safeguard residents from potential abuse, and ensures residents are supported by competent, skilled and well-supervised staff. EVIDENCE: The manager is able to evidence both verbally and through documentation that she takes seriously the importance of recruiting the right staff to the home to meet the residents needs, but also to ensure they are fit to work with vulnerable adults. The manager is aware of the new legislation around checking potential staff’s employment history, that they have two credible references and have a “first” POVA (Protection of Vulnerable Adults) check before commencing employment in the home. The manager was also aware that new staff must have a have CRB (Criminal Record Bureau) check undertaken on them. This was evidenced at the time of the visit as a new member of staff was working fully supervised and supernumery from the rota until such time her CRB was returned. The home uses an umbrella body for undertaking CRB checks and is currently in the process of resubmitting all staff for checks to ensure they are up to date, especially for those staff who have moved house or who are overseas staff. The requirement made following the previous visit to provide the Commission for Social Care Inspection with a training plan has been met. The manager provided evidence of staff training and the inspector met with two staff who Harefield Lodge H55-H03 S11916 Harefield Lodge V218907 100505.doc Version 1.30 Page 21 confirmed that they had received mandatory training and service specific training, such as food hygiene, health and safety, first aid, manual handling adult protection, medication, challenging behaviour, including breakaway techniques, stress management and essential, advanced and Makaton communication training. The staff spoke highly of the support and encouragement they are given to attend training courses. Seven of the ten staff have or are undertaking an NVQ 2 or 3 in care, this demonstrates a commitment to ensure the home is equipped with a competent and skilled workforce. As described in standard 23 the residents have their own post office accounts, some have ownership of these, or the company has appointeeship. There is a clear audit trail and computer system that details the residents’ balances, money received and elements deducted for rent. Residents who have ownership of the accounts are supported to collect their money and can safely deposit it in the home’s safe if they wish. The manager is the only person who has access to the homes large safe, however there is an audit trail of monies transferred from one safe to another small safe, which is checked every shift. Residents balance details are received in the home monthly. The staff with which the inspector spoke with said they felt very well supported and motivated by their manager. They stated that the manager regularly meets with them to discuss their work practices, any concerns they may have with their key residents and their training needs, in addition the manager negotiates objectives with them, which they said kept them interested and motivated in their job. This was demonstrated by the very good work in putting the medication guidance pack together and nominating a member of staff to be the activities coordinator. Discussion took place with the manager, staff and the inspector on ideas for person centred planning and alternative communication tools. Harefield Lodge H55-H03 S11916 Harefield Lodge V218907 100505.doc Version 1.30 Page 22 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) 37,39 and 42 The residents benefit from a well run home that is open and inclusive, seeks their views and is far as feasibly possible provides a safe environment for them to live in. However the manager must ensure all electrical appliances are safe to use EVIDENCE: The manager was registered with the Commission for Social Care Inspection in March 2005 following a long period as acting and appointed manager. The manager demonstrates that she is aware of her roles and responsibilities and is always willing to take on board new ideas and challenges. The manager is observed to have a relaxed but assertive approach with staff and gets the best out of them by working with them. She makes herself fully aware of the needs of the residents and is visibly involved in supporting both the residents and staff. The requirement issued following the previous visit for the manager to provide the Commission for Social Care Inspection with the outcome of the quality audit has in part been met. The company’s operational manager requested an Harefield Lodge H55-H03 S11916 Harefield Lodge V218907 100505.doc Version 1.30 Page 23 extension on the timescale for the completion of quality audit this was agreed. At the time of the visit a resident was discussing meeting with a member if staff to go through the some of the quality questionnaire. The questionnaire is thorough and covers all aspects of the residents’ health and welfare. The resident stated she had enjoyed working through the questions. A member of staff stated it had helped her to get to know the resident better and assist with her project to improve in house and social activities. All requirements issued following the previous inspection to ensure the home maintains a safe environment for residents to live has been met and there was evidence of regular health and safety checks and checks on the homes fire systems and equipment. There was evidence that there were up to date checks on the home electrical, gas and water system, however the home is required to undertake an annual inspection on all portable appliances, as there was recorded evidence that they were out of date. Harefield Lodge H55-H03 S11916 Harefield Lodge V218907 100505.doc Version 1.30 Page 24 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 x 3 x x Standard No 22 23 ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 x 2 x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 2 3 Standard No 31 32 33 34 35 36 Score x x x 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Harefield Lodge Score 3 3 4 x Standard No 37 38 39 40 41 42 43 Score 3 x 2 x x 2 x H55-H03 S11916 Harefield Lodge V218907 100505.doc Version 1.30 Page 25 yes 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 YA6 YA7 Regulation 12 Requirement The registered manager must develop the residents individual plans in a way that meets their communication and cognitive abilities and empowers them to take ownership of their plans. The manager must ensure personal plans document the name the service user wishes to be known by. This requirement has been repeated. A further failure to comply will result in further action being taken. The registered manager must ensure that all residents are issued with the complaints procedure in a format suitable to meet the communication and cogintive ability. The registered manager must ensure that the bathrooms are repainted as identifed at the time of the inspection. The registered manager must ensure the flooring in the downstairs toilet are replaced to erradicate the unpleasent odour. The registered manager must ensure all portable electrical appliances are checked and safe to use. Timescale for action 31/12/05 2. YA16 12(3) 31/08/05 3. YA22 22(2) 30/09/05 4. YA27 23(2)(d) 31/10/05 5. YA27 16(2)(k) 31/10/05 6. YA42 23(2)(c) 31/08/05 Harefield Lodge H55-H03 S11916 Harefield Lodge V218907 100505.doc Version 1.30 Page 26 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 Good Practice Recommendations Harefield Lodge H55-H03 S11916 Harefield Lodge V218907 100505.doc Version 1.30 Page 27 Commission for Social Care Inspection 4th Floor, Overline House Blechynden Terrace Southampton SO15 1GW 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 Harefield Lodge H55-H03 S11916 Harefield Lodge V218907 100505.doc Version 1.30 Page 28 - 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. 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