Inspection on 03/10/06 for Harefield Lodge

This inspection was carried out on 3rd October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Harefield Lodge 08/11/05

Harefield Lodge 23/06/05

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 Janet Ktomi Unannounced Inspection 3rd October 2006 10:00 Harefield Lodge DS0000011916.V307913.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 Harefield Lodge DS0000011916.V307913.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. Harefield Lodge DS0000011916.V307913.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Harefield Lodge Address 6 Westwood Road Southampton Hampshire SO17 1DN 023 8055 5802 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) ILIACE Limited Sonia Beverley Osborne Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Harefield Lodge DS0000011916.V307913.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection New Service Brief Description of the Service: Harefield Lodge provides care and support for up to 10 younger adults with learning disability and challenging behaviour. Help is given when required but service users are supported to live their lives as independently as possible. Harefield Lodge is a large detached 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 facilities and separate lounge area. There is a lounge and separate dining room and a spacious enclosed garden. Harefield Lodge was purchased in March 2006 by ILIACE Limited, an organisation with a number of homes in the South of England. The home is managed by registered manager Ms Sonia Osborne. Harefield Lodge DS0000011916.V307913.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report contains information gained prior to and during an unannounced visit to the home undertaken on the 3rd October 2006. The inspector would like to thank the people who live at the home, the manager and the staff for their full assistance and co-operation with the unannounced visit. The visit to the home was undertaken by one inspector and lasted approximately six and a half hours commencing at 10.00 a.m. and being completed at 4.30 p.m. This was the first inspection for a new service therefore all core standards and a number of additional standards were assessed. The inspector was able to spend time with the care staff on duty and was provided with free access to all areas of the home, documentation requested and service users. Prior to the visit a pre-inspection questionnaire was sent to the home and returned within the required time scale. External professional questionnaires were sent to people identified in the pre-inspection questionnaire as having regular contact with the home. A comment card was returned from one GP. Service user and relative comment cards were sent to the home. Two service user comment cards were received. Information was also gained from the link inspector. During the visit to the home the inspector was able to meet with and talk to all of the people who live at the home, some of whom showed the inspector their private accommodation. What the service does well: All service users stated that they liked living at the home and that the staff and manager were all kind and helpful. Service users have active lives and are supported to follow their interests and maintain contact with family and friends. Most service users have lived at the home for many years and have highly individual private accommodation (bedrooms). Service users’ complex health and social support needs are well met, with clear care plans and risk assessments in place. Harefield Lodge DS0000011916.V307913.R01.S.doc Version 5.2 Page 6 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. Harefield Lodge DS0000011916.V307913.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 Harefield Lodge DS0000011916.V307913.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 4. Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. Prospective service users have the information they need to make an informed choice about where they live. The home would only admit people whose needs it could meet and who would be compatible with the people already living at the home. EVIDENCE: The manager showed the inspector the home’s statement of purpose and service users’ guide. This contained all the necessary information, however the information in respect of the provider and registered manager was incorrect, stating the previous provider and previous registered manager. The manager updated this during the inspector’s visit and therefore no requirement is made in respect of this. In addition to the typed information (more suitable for professionals and relatives than service users) the home has produced an audio tape version of this information along with other relevant information for each individual service user. Individual service user’s information packs containing the audio tape were seen during the visit, some service users have opted to keep these in their rooms, others are available for the service user in the office. Pre-inspection information provided by the manager stated that the home has not admitted any new people since 2002. The manager confirmed this during Harefield Lodge DS0000011916.V307913.R01.S.doc Version 5.2 Page 9 the inspector’s visit. The home currently has two vacancies. The manager explained the admission process that would occur should the home receive a referral for admission. This would include the manager and another senior person in the company undertaking a thorough assessment of the person, including gathering information from professionals, any relatives and the referred person. Together they would decide if the referral was appropriate and if the home could meet the person’s needs. The company and the funding authority would then confirm funding arrangements and then the manager would commence the person’s introduction to the home. The length of introduction would depend on the referred person’s needs. The manager was clear that existing service users would be included in the decision about whether someone should be admitted to the home and that specific staff training would be provided if necessary. Staffing levels would also be considered and may be increased if the person had complex needs indicating a need for a high level of support. Harefield Lodge DS0000011916.V307913.R01.S.doc Version 5.2 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 the following standard(s): 6, 7, 8 and 9. Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. All service users have individual care plans. Care plans contain relevant risk assessments. Service users are encouraged to make choices and their personal finances are appropriately managed. EVIDENCE: The inspector viewed the care plans for three of the people who live at the home. These included people with high support needs. The care plans were seen to detail the support people required to meet their daily and longer term needs. Care plans were seen to contain risk assessments covering general and specific risks to the individual. Each service user has a personal plan that has been completed using a person centred approach and was seen to have been signed by the service user. Each plan is very detailed identifying their strengths, needs and risks and how staff should support them. The manager has also produced quick access (short) versions of care plans for agency staff that contain the important information to enable new staff to meet service Harefield Lodge DS0000011916.V307913.R01.S.doc Version 5.2 Page 11 users’ needs. Each service user has an allocated key worker with some service users informing the inspector of the name of their key worker. Care plans were seen to have been reviewed on a regular basis. Service users informed the inspector that they were able to make choices and decisions about how they spend their lives. Throughout the visits to the home service users were seen giving opinions and making decisions that were respected by the staff. Risk assessments were in place for some activities whereby restrictions may have been placed on service users. These were in respect of health and safety for both the individual concerned and other people living in the home. Risk assessments had been completed in a positive way to identify risks and determine how these risks could be managed to enable people to continue to undertake activities in a safer way. Service users stated that they are able to spend their own money on what they wished. Service users confirmed that staff support them with personal shopping. The manager explained that each service user has an individual bank/building society account into which their state benefits and allowances are paid by direct credit transfer. The manager explained the way in which the home supports service users to manage their personal money and these arrangements would seem appropriate. Records are maintained in respect of the spending for individual service users and these were seen during the visit. The pre-inspection questionnaire stated that the manager is appointee for four service users with family members being the appointee for the other people living at the home. Service users were seen to be encouraged to participate in routine domestic activities, informing the inspector that they help with the food shopping. During the visit to the home service users were seen assisting with the preparation of the lunchtime meal and making themselves drinks throughout the day. Service users confirmed they had chosen what they were going to have for their lunchtime meal and were involved in discussions about their evening meal with care staff in the afternoon. Service users were seen bringing dirty laundry to the home’s laundry room which they informed the inspector the staff then washed for them. Care staff stated that they try to involve service users in cleaning and tidying their own rooms, some people who live at the home being more enthusiastic than others in respect of domestic chores. Harefield Lodge DS0000011916.V307913.R01.S.doc Version 5.2 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 the following standard(s): 11, 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. Service users have varied and active lives, are able to participate in their local community and have visitors to the home. Service users are offered a healthy diet and enjoy their meals and mealtimes. EVIDENCE: The inspector was able to meet with and talk to all of the people who live at the home. Two of the service users returned pre-inspection comment cards. Service users talked with the inspector about what it is like living at Harefield Lodge. Service users talked about their weekly activities and the recent holiday they had taken. Service users all have individual weekly plans containing a range of external activities (day services and supported work placements) as well as leisure activities in the evenings and at weekends. A white board in the office contains details of each service user’s usual weekly activities. Service Harefield Lodge DS0000011916.V307913.R01.S.doc Version 5.2 Page 13 users are encouraged to undertake domestic tasks but can opt out if they choose to do so. One service user was seen taking his dirty laundry to the laundry room and informed the inspector that the staff would then wash it for him. As well as planned weekly activities the home also organises ad hoc activities such as trips to pubs and places of interest. Activities and social events undertaken are recorded in the daily records in care plans. Service users stated in the comment cards returned prior to the visit that they have lots of things to do and that they enjoyed living at the home. The home has a minibus capable of transporting all the service users. The home does not make a charge for this service that is funded by the organisation. All of the service users had been on holiday the week prior to the inspector’s visit to the service. They confirmed that they had chosen where they were going. Most had gone together with one service user opting for a quieter holiday in the New Forest. The service users had clearly enjoyed their holidays and informed the inspector they hoped to go again. Staff stated they had also enjoyed the holiday. Service users are not charged for the holiday that is included within the service contract with the funding by social services. Service users also enjoy a range of in-house leisure activities and were observed listening to music, watching television, knitting and doing art work. Bedrooms were seen to contain home entertainment equipment and items of personal leisure occupation. The home is in the process of converting a small vacant bedroom into a relaxation/sensory room. This was seen during the visit and is well on the way to completion. The home employs an activities worker every weekday. Unfortunately she was on a day’s sick leave during the inspector’s visit. The manager explained her role and service users discussed what they enjoyed doing with her. Activities were individual to the service user as well as some group activities. The inspector believes that service users have a good lifestyle with varied activities on offer. Daily records contained details of what individual service users had eaten. These indicated that service users are provided with a varied nutritious diet. During the visit to the home the inspector was able to talk to staff and observe the meal preparation for people at home during the visit. Food is prepared by the care staff on duty, where appropriate with the assistance of service users. The main meal on weekdays being in the evening and a take-away on a Saturday evening. Some service users prepare their own packed lunches to take to day services. Staff were aware of individual likes and dislikes of the people who live at the home. Although there were no visitors to the home during the inspector’s visit service users confirmed that they could invite friends or family to visit. One stating that her sister who lives close by visits her one Sunday and that she visits her sister the other Sunday. This was also seen recorded in her care plan and daily Harefield Lodge DS0000011916.V307913.R01.S.doc Version 5.2 Page 14 records. The home does not have a private meeting room. The manager explained that she is intending on rearranging the dining room to provide a comfortable seating area as well as dining tables. The room is more than big enough to allow this. This could then provide a place for more private visits if this was required. Harefield Lodge DS0000011916.V307913.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. Service users receive personal support in the way they prefer and require and their physical and emotional health needs are met. Appropriate systems are in place for the safe storage and administration of medication. EVIDENCE: Throughout the inspection visit the inspector met all of the people who live at the home. Everybody appeared to have been well supported with their personal care needs. Two comment cards were received from service users and these stated that they always receive the care and support they require. Individual care plans provided information as to how personal care needs should be met with specific risk assessments and risk management plans in place to promote maximum independence during personal care activities. Records of personal care are maintained in daily records. Service users spoken with during the visit stated that staff provide assistance with personal care. All bedrooms are for single occupancy therefore affording a Harefield Lodge DS0000011916.V307913.R01.S.doc Version 5.2 Page 16 high level of privacy. The home is in the process of providing an additional walk in shower room on the ground floor near the rear of the home. This has almost been completed and will enable the two service users whose bedrooms are on the ground floor to have access to a ground floor shower room. The home does have a key worker system, however due to a number of staff changes this has not been fully implemented. The manager stated that once all the new staff are in post and have completed their induction the key-worker allocations will be finalised. Care plans contained information about service users’ health needs and how these had been met including records of GP, hospital and optician appointments. A comment card was received from the home’s GP that stated that he had no concerns about the home and was satisfied with the overall care provided to service users. The manager explained the procedures for the management of medication within the home. All medication was seen to be stored securely. The home uses pre-dispensed blister packs where possible. The manager confirmed that medication is dispensed by one person who then gives the medication directly to the person for whom it has been prescribed. Some care staff and the manager have completed external distance learning training in medication management and administration whilst newer staff have not attended external training but been trained in-house and been deemed competent by the manager. The manager stated that all staff would do external medications training. The inspector observed the Medication Administration records. Medication coming into the home is recorded on the MARs sheets as is that administered. Records seen were fully completed and the manager stated she checks MARs sheets regularly to ensure they are fully completed. The home keeps the patient information leaflets about medication prescribed with the MARs sheets. Information about as needed (prn) medication was also seen in care plans and with MARs sheets. Harefield Lodge DS0000011916.V307913.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. The people who live at the home are able to make complaints that would be appropriately investigated and resolved. The home would respond appropriately to adult protection concerns. EVIDENCE: The pre-inspection questionnaire completed by the manager stated that there had been no complaints to the service during the previous year. The comment cards completed by the service users also stated that they had no complaints or concerns. The home’s complaints procedure is detailed in the service users’ guide and is also included on the audio tape provided to each service user. Discussions with the people who live at the home indicated that they would tell a member of staff or the manager if they had any complaints. Discussions with care staff indicated that any complaints would be listened to and appropriate action taken either to immediately resolve the problem or to inform the manager. Observations of the interactions between the people who live at the home and care staff and the manager indicated that they would be able to discuss any concerns or make complaints to the staff or manager. All service users have been provided with pre-written and stamped postcards to the provider that states that the service user has a complaint or concern and would like to discuss it with them. Most of the people who live at the home attend external day services, work placements and clubs, they would therefore be able to discuss concerns with people not related to the home. The home Harefield Lodge DS0000011916.V307913.R01.S.doc Version 5.2 Page 18 encourages service users to express their opinions and service users were seen telling staff what they wanted for their evening meal. Comment cards were received from two service users who confirmed that staff listen and act on what they say. Discussions with the manager and care staff indicated that they were aware of the action they should take should they have concerns that a service user may be at risk of abuse. The manager showed the inspector the home’s induction workbook and this contains information about the protection of vulnerable adults. Risk assessments for individual service users contained assessments relating to the protection of vulnerable adults. The manager is part of the Southampton POVA group and during discussions demonstrated a very good understanding and attitude to the rights and responsibilities of vulnerable adults to be protected from abuse. The home has previously notified the Commission and social services about concerns they had that a service user may be at risk of abuse. These concerns were not in respect of the home but when the service user was elsewhere. The actions taken would indicate that the home would take appropriate action in the event that there were adult protection concerns. The recruitment and management of service users’ personal finances are discussed in more detail elsewhere in the report. The home has appropriate policies, procedures and records to indicate that unsuitable people would not be employed at the home and that service users’ personal finances are appropriately managed. Harefield Lodge DS0000011916.V307913.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28 and 30. Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. Service users live in a well maintained, homely, comfortable, clean and safe environment appropriate for their individual and collective needs. EVIDENCE: The manager showed the inspector round the home including all communal areas, bathrooms, the new sensory room, vacant bedrooms and some service users’ bedrooms. Two service users showed the inspector their bedrooms. Harefield Lodge is a large detached house situated in a quiet residential road in 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 en-suite and separate lounge area. There is a lounge and separate dining room and a spacious enclosed garden. The stair and hallway (upstairs and downstairs) carpets have been replaced since the home was purchased by the new providers. As stated all bedrooms are single, one with en-suite facilities. Bedroom doors are fitted with locks with the inspector noting that some service users choose Harefield Lodge DS0000011916.V307913.R01.S.doc Version 5.2 Page 20 to lock their bedroom doors and others chose not to do so. Bedrooms seen contained all the required furniture and fixtures, those without en-suite facilities having washbasins. Bedrooms seen had been individualised by their occupants and were all of a good size. Some bedrooms have been redecorated since the new owners purchased the home. The home had one smaller bedroom. This is now being converted to provide a relaxation/sensory room. The manager showed the inspector this room that is nearing completion. The home has a large pleasant lounge and very good sized dining room. As previously stated the manager intends to rearrange the dining room and provide a comfortable seating area. The manager showed the inspector some large photo frames that are intended to be filled with pictures of the service users and placed on the dining room walls. This will help make the room feel less bare. The manager also stated that she is hoping to replace the pictures in the lounge with some chosen by the service users. The home also has a good sized pleasant garden with decked area and garden furniture. Service users confirmed that they had enjoyed spending time in the garden in the summer. The home has an appropriate number of bathroom, shower rooms and WCs located around the home. As previously mentioned an additional walk in shower room has almost been completed on the ground floor. Service users confirmed that there were adequate numbers of WCs and bathrooms and they do not have to wait to use these facilities. At the time of the unannounced inspection the home was found to be clean, tidy and free from offensive odours. Care staff confirmed that they had adequate supplies of disposable gloves and other equipment for infection control. Laundry facilities are appropriate for the size of the home and located in a laundry room that is kept locked when not in use by staff. Harefield Lodge DS0000011916.V307913.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 and 36. Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. The home has a suitably recruited, trained and experienced staff team that it provides in sufficient numbers to meet service users’ needs. All staff must receive formal supervision at least six times a year and an annual appraisal. EVIDENCE: The home has experienced staffing problems following the manager being informed by the home office that four members of staff did not have the necessary legal papers to allow them to work in England. Some of these staff had worked at the home for several years and the manager had been unaware that documents provided have been falsified. The home has therefore relied on a consistent group of agency staff with the manager working long hours as care to ensure that service users’ needs have continued to be met. The manager stated that she has now recruited new staff, who have either commenced employment recently or are due to commence working in the home in the very near future once all the required checks have been completed. It is to the manager’s credit that service users’ needs have Harefield Lodge DS0000011916.V307913.R01.S.doc Version 5.2 Page 22 continued to be met, activities and holidays undertaken during this difficult period. On the day of the unannounced visit the home was staffed by one permanent member of care staff, one new agency worker and the manager. The manager stated that she is now able to rota herself with some office shifts as opposed to always being counted in the care numbers. The home usually aims to provide two care staff throughout the day with one staff at night. In addition an activities person is provided weekdays from 9 a.m. to 3 p.m. When discussing the home’s admission procedure the manager stated that staffing levels would be reviewed if a new person was admitted to the home. If the new service user had high support needs additional staffing would be provided. The staffing levels would seem appropriate to the needs and number of people living at the home. Care staff undertake all domestic and cooking tasks and try to encourage service users to participate. Care workers stated they have sufficient time to complete all the tasks and spend time with service users in leisure activities. The inspector spoke with the one permanent member of care staff on duty throughout the visit to the home, she was clear about her role and responsibilities and demonstrated a good understanding of service users’ needs. Records of care staff training were supplied with the pre-inspection information. This indicated that permanent care staff have received appropriate training to meet service users’ needs. The home currently has six care staff (excluding agency workers). The manager informed the inspector that two have an NVQ level 2 in care, an additional two carers are undertaking this qualification and a further one is due to commence their NVQ in November. The final member of care staff is on long term sick leave and does not have an NVQ qualification. The home is therefore taking the necessary action to ensure that at least fifty percent of its care staff have an NVQ in care and therefore no requirements are made in respect of the fact that at the time of the inspection the home was below the required number of care staff with an NVQ. The carer on duty at the time of the inspector;s visit stated that she felt she had the necessary skills to support service users. As stated the manager has recruited new staff since the home was purchased by the current providers. The manager explained the home’s recruitment processes that would seem thorough and appropriate. Recruitment records were viewed and contained evidence that all the required checks had been undertaken. The manager showed the inspector the induction training and documentation that was comprehensive and would cover all the necessary areas for new staff. The manager stated that she is to attend a study day on the common induction standards. The manager informed the inspector that she has not been able to maintain the appraisals and supervision sessions for care staff due to the pressure on staffing identified earlier in this section. The manager stated that she has Harefield Lodge DS0000011916.V307913.R01.S.doc Version 5.2 Page 23 worked with staff and supervised their practise but has not undertaken the regular formal supervision sessions. The member of care staff stated that she could ask the manager any questions and that the manager was always available either in the home or on call should she require advice or guidance. The manager confirmed that the company has an on call system such that care staff always have access to a manager (from their own or another home). Records seen in staff files confirmed that formal supervision sessions have not been occurring on a regular basis. Now that staffing issues are resolving, and the manager is able to allocate herself admin/management time all staff must have formal appraisals and supervision sessions. Harefield Lodge DS0000011916.V307913.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 41 and 42. Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. The home is well managed and run in the best interests of the service users. Records are well kept and the home is a safe place for service users, staff and visitors. The manager must be provided with written reports following every Regulation 26 visit by the provider’s representative. The manager must be provided with written feedback and analysis of quality assurance work undertaken by the providers. EVIDENCE: The manager has successfully managed the home during a difficult period of time and has worked hard to maintain the level of service provided to service users. The manager has an NVQ level 4 in care and the A1 assessor’s award Harefield Lodge DS0000011916.V307913.R01.S.doc Version 5.2 Page 25 for NVQs. The manager stated that she has almost completed the Registered Manager’s award and anticipated that this would be completed by January 2007. Service users stated that the manager was approachable and would sort out any problems for them. Throughout the inspector’s visit to the home service users were noted to ask the manager questions and that appropriate responses were always provided. It was evident throughout the inspector’s visit that the service users felt relaxed and at ease with the manager. Care staff confirmed that the manager is supportive and helpful and has worked long hours to maintain the service provided to the people who live at the home. The manager was open and honest about the service and the areas she is aware need improvement. The manager stated that she felt well supported by the provider’s management structure. The inspector was shown the provider’s quality assurance system. This is comprehensive and allows for quality assurance on all areas of the service from recruitment of staff to provision of service to service users with questionnaires for staff, service users and relatives. The manager explained that completed questionnaires are sent to the provider’s main office, however she has not yet received feedback from the quality assurance work undertaken in the home. The provider must ensure that the manager is provided with feedback from all quality assurance work undertaken. Without feedback the manager cannot implement any necessary changes to improve the service provided. The manager stated that a representative of the provider visits the home at least every month and undertakes a review of the service as required under Regulation 26. The manager showed the inspector some of the reports she has received following these visits, however she did not have a report for every month including August and September 2006. Without a copy of the report the manager is unable to implement any changes necessary or address issues identified during the visit that may be undertaken at a time when she is not present in the home. If the manager has not received a report then it may be that the Responsible Individual for the company may also not have received a report. The responsible individual is legally responsible for the service provided. The manager must receive a written report following every Regulation 26 visit to the home by a representative of the provider. These reports must be available in the home for inspection. Throughout the unannounced visit to the home a variety of records was viewed by the inspector. With the exception of the Regulation 26 visit reports and the quality assurance reports all records were all found to be well maintained and stored appropriately to ensure confidentiality. The home ensures as far as is reasonably practicable the health, safety and welfare of service users, visitors and staff. Staff are appropriately recruited and receive the necessary induction and ongoing training to meet service users’ general and specific needs. The home has safe working practices and was seen Harefield Lodge DS0000011916.V307913.R01.S.doc Version 5.2 Page 26 to be well maintained. Comprehensive general and specific risk assessments are in place for all service users. Harefield Lodge DS0000011916.V307913.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 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 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 2 X 3 3 X Harefield Lodge DS0000011916.V307913.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? New service 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. 2. Standard YA36 YA39 Regulation 18 (2)(a) 24 Requirement All staff must receive formal supervision at least six times a year and an annual appraisal. The provider must ensure that the manager is provided with feedback from all quality assurance work undertaken. The manager must receive a written report following every Regulation 26 visit to the home by a representative of the Responsible provider. These reports must be available in the home for inspection. Timescale for action 01/12/06 01/12/06 3. YA39 26 01/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Harefield Lodge DS0000011916.V307913.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Southampton, Portsmouth and Isle of Wight Ground Floor Mill Court Furrlongs Newport, IOW PO30 2AA 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 DS0000011916.V307913.R01.S.doc Version 5.2 Page 30 - 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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