Inspection on 23/01/06 for Hart Lodge

This inspection was carried out on 23rd January 2006.

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 no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hart Lodge 04/09/07

Hart Lodge 01/08/06

Hart Lodge 30/06/05

Hart Lodge 19/11/04

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

CARE HOME ADULTS 18-65 Hart Lodge 10 Whalebone Grove Chadwell Heath Romford Essex RM6 6BU Lead Inspector Joanna Moore Unannounced Inspection 23rd January 2006 10:00 Hart Lodge DS0000059918.V282415.R01.S.doc Version 5.1 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 Hart Lodge DS0000059918.V282415.R01.S.doc Version 5.1 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. Hart Lodge DS0000059918.V282415.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Hart Lodge Address 10 Whalebone Grove Chadwell Heath Romford Essex RM6 6BU 020 8590 7077 020 8500 9339 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) R Hart Care Ltd Mr Gerald Rueben Mhlanga Care Home 9 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (9) of places Hart Lodge DS0000059918.V282415.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th June 2005 Brief Description of the Service: Hart Lodge a registered service for nine people of either sex who have mental health needs which has been registered. Hart Lodge opened in the latter Part of 2004 and this is the second inspection carried out under the Care Standards Act. The inspector was advised that current referrals are mainly as part of the re-provision from long stay hospitals. At the time of the inspection the home was full. The building is situated in a residential area which is accessible to central Romford shopping amenities via local bus routes and is easily reached by road from the A12 and A13. The service users are physically mobile, of either sex and aged between 18-65 years. The building had been converted and provided a high standard of accommodation. Hart Lodge is owned by Hart Care Ltd which have owned and operated another mental Health home in the Southend area for two years. Hart Lodge DS0000059918.V282415.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the annual inspection program and in relation to a complaint made to the Commission. The focus of this inspection was to review whether the home had addressed the requirements and recommendations from the previous inspection, medication practices, and staff and management support to each other and service users. The Pharmacist inspector accompanied the lead inspector on this visit and their findings have been included in this report. What the service does well: What has improved since the last inspection? What they could do better: The home must improve on its medication systems for those people who are self medicating. Hart Lodge DS0000059918.V282415.R01.S.doc Version 5.1 Page 6 The home needs to ensure that care plans and risk assessments are regularly reviewed and updated for all service users. 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. Hart Lodge DS0000059918.V282415.R01.S.doc Version 5.1 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 Hart Lodge DS0000059918.V282415.R01.S.doc Version 5.1 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): EVIDENCE: At the previous inspection all standards in this section were assessed as met and were not assessed again as part of this inspection. Hart Lodge DS0000059918.V282415.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8&9 Service users and staff benefit from a detailed care plan however this needs to be reviewed regularly to reflect service users changing needs and aspirations. Service users were consulted on all issues regarding their lives and the day-today running of the home. EVIDENCE: Two service users care files were reviewed as part of this inspection. A clear care plan was in place for both and this was linked to the statutory care program approach in place. Statutory timescales for reviewing had been adhered to under the CPA but for one service user the internal care plans were not recorded as reviewed regularly and updated to reflect changes. The other service users care plan was updated quarterly. The registered person is required to ensure that care plans are reviewed and updated regularly and at least six monthly. Risk assessments were in place but for one service user had not been reviewed in the previous fourteen months. The registered person is required to ensure that risk assessments are reviewed and updated on a regular basis. One service user was self-medicating but there was no care plan in place to support this. The registered person is required to ensure that selfHart Lodge DS0000059918.V282415.R01.S.doc Version 5.1 Page 10 medicating service users have this clearly identified and supported by a care plan. Hart Lodge DS0000059918.V282415.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 Service users rights and responsibilities are recognised and supported. EVIDENCE: At the previous inspection all key standards in this section were assessed as met and were not assessed again as part of this inspection. On the day of the inspection a solicitor came to the home and met with service users to discuss their rights under the mental health act and the legal advocacy service available to them. The solicitor advised the inspector that this had been arranged by the manager of the home. Two service users were particularly interested in this service and went on to discuss their situations individually in private. Information on advocacy services was available and displayed on the notice board in the communal lounge area. Hart Lodge DS0000059918.V282415.R01.S.doc Version 5.1 Page 12 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): 19 &20 Medication arrangements within the home generally safeguarded service users but the arrangements for people self-medicating were not sufficiently robust. Service users physical and emotional health needs are met. EVIDENCE: Care records evidenced that service users aware having regular and appropriate support from relevant professionals e.g. psychiatric nurse or social worker, consultant psychiatrist, GP however this information was not easily available it is recommended that the home consider the use of a health care monitoring record. Some service users are on a weight reducing diet it is recommended that a referral to the dietician be made for these service users in order to ensure correct dietary advice for their specific needs is given. The inspector was advised that all service users are registered with a dentist. Service users have their blood tested regularly in accordance with the guidelines for the medication they are receiving. The pharmacist inspector reviewed medication arrangements in detail and sent the home the following report: “Although the handling of medicines was generally satisfactory, there was concern raised by discrepancies in the audit of medication for which Hart Lodge DS0000059918.V282415.R01.S.doc Version 5.1 Page 13 improvement is required with the recording of medicines administration to ensure that medicines are administered in accordance with the prescriber’s directions. The tables on the following pages provide further information on this issue and indicate the requirements and recommendations arising from the inspection. Action must be taken to meet requirements as they are made under the Care Standards Act 2000. Recommendations are seen as good practice and should be given serious consideration. References where further information may be obtained have been provided in the table’s left hand column below the item code and the titles of the references given on the last page of this report. Item code/ References A. 1) 20.6 2) Timescale for action Immediate 2) 2) 2) 2) B. 3.0 3.2.2 3.3 6.2.3 2) 2) 2) 2) C. 2.0 3.2.1 6.1 6.2.3 D A copy of the current edition (2003) of The Royal Pharmaceutical Society’s (RPSGB) publication entitled “The Administration and Control of Medicines in Care Homes and Children’s Services” was provided for reference at the time of this inspection. The audit of medication indicated that the Immediate doses of two medicines prescribed for regular administration for one service user had apparently been omitted without reason on the morning of 21 January 2006. There was no entry made on the medicines administration record (MAR) chart and the manager had not been informed. (Immediate Requirement notice refers) The home’s risk assessment procedure for Immediate allowing service users (SU) to selfadminister their medicines (SAM) has to be met and the assessment forms to be completed prior to a SU commencing selfadministration. A suggested documented SAM programme was given to the home’s manager that included monitoring forms to maintain a record of a SU’s progress with their SAM. The use of compliance devices e.g. Dosett, By 23 April Hart Lodge DS0000059918.V282415.R01.S.doc Version 5.1 Page 14 2) 2.0 2) 4.9 E. 2) 6.2.3 Medidos, in the home as an aid for service users self-administering their medicines or for short periods of unplanned leave, etc., requires a written policy/procedure. Reference should be made to indicate the staff qualified to transfer medicines to the devices and the precautions/checks required. The transfer of some medicines from the manufacturer’s packaging may be contraindicated. If in doubt contact your pharmacist for advice. There were examples of dosage administration not being recorded on the medicines administration record (MAR) charts, in addition to item B above, that require investigation by the home’s manager. 2006 or before the further use of compliance devices, whichever is sooner By 30 January 2006 Hart Lodge DS0000059918.V282415.R01.S.doc Version 5.1 Page 15 Item code/ References F. 2) 11.0 G. 2) 3.0 2) 3.2.2 2) 3.2.3 H. 2) 6.2.3 I. 2) 6.2.3 J. 2) 6.2.3 The home’s staff are to be updated on the requirements for the medicines administration procedures indicated in this report. In order to provide the complete medication profile for all service users (SU) it is necessary to record all the medicines for each SU on a current medicine administration record (MAR) chart. This includes any medicines that a SU may receive away from the home, for example, a depot injection given at a clinic, as well as those prescribed and non-prescribed (including homely remedies), prescribed dietary supplements, medicines for external use, diagnostic testing agents, medicines not administered during the 4-week duration of the MAR (given at intervals of longer than 4 weeks), etc. In view of both standard and monitored dosage system medicine containers being used in the home, some incidents resulting in blank medicine administration record (MAR) chart entries and doses being missed, the home would benefit from reorganising their storage of medicines. I believe that risk reduction of medicines being omitted may be achieved by storing medicines according to service user as opposed to container type, as discussed. Guidance is required in the home’s medicines policies for when the directions for medicines administration are variable, e.g. one or two tablets or 5 to 10 mls., etc., with the dose given to be entered in the dose record section of the medicine administration record (MAR) chart. A current list of staff members authorised to administer medicines should be retained with the medicine administration record (MAR) charts, including a record of their signatures and signed initials. Timescale for action Immediate Immediate By 30 January 2006 By 23 February 2006 By 23 February 2006 Hart Lodge DS0000059918.V282415.R01.S.doc Version 5.1 Page 16 Item code/ References K. 2) 3.2.1 2) 3.2.2 L. 2) 5.1 2) 6.2.3 M. 2) 3.0 2) 3.1 N. 2) 6.2.2 For accountability any entries made to medicine administration record (MAR) charts require endorsement with the date of entry and the signed initials of the authorised person making the entry, as discussed. Avoid the use of abbreviations when entering dosage directions and include the strength of the preparation, when stated When the administration of medicines is required away from the point of medicines storage, it is necessary to provide for the secure carriage of medicines for administration and immediate security in the case of the carer being called away to an emergency. This may be satisfied for example by using a mobile lockable facility, for example, a suitable purpose-made medicines case. Your dispensing pharmacist should be able to assist you with the availability of suitable designs and suppliers. The record entered on the medicines administration record (MAR) chart of medicines received into the home is to include the date of receipt, in addition to the quantity received and signature of the person receiving. This is to include those medicines received outside the four week dispensing cycle and any carried forward from the previous MAR chart in addition to the repeat-dispensing items, as demonstrated. This not only avoids the risk of transcription errors when transferring details to a separate record document but also provides accountability for the audit trail on the current MAR chart. A copy of a protocol addressing the issue of administering medicines to service users with swallowing difficulties was provided during the inspection. Timescale for action Immediate By 23 February 2006 Immediate Immediate Hart Lodge DS0000059918.V282415.R01.S.doc Version 5.1 Page 17 Item code/ References O. 2) 2.0 2) 6.2.3 P. 2) 2.0 2) 4.14 Q. 2) 6.2 R. 2) 6.2.5 2) 6.2.6 Timescale for action By 23 The home’s written policy/procedure for dealing with medicines administration errors February requires some reorganisation, as discussed, 2006 to provide clear guidance to staff on the action to take and the procedure to be followed when unable to contact the service user’s GP/pharmacist, for example contacting NHS Direct. The homely/household/domestic remedies By 23 April policy for treating any minor ailments 2006 presented by service users (SU) included preparations that are inappropriate for this purpose, for example, multivitamins (longer-term treatment for more chronic conditions) and Lemsip (contains a decongestant that can particularly interact with prescribed psychotropic medicines). A suitable range of remedies and other requirements for inclusion in the policy were discussed at the time of the inspection. The signed agreement of the SU’s GPs/psychiatrists should be sought when the policy has been completed. There were currently no homely remedies available in the home. A copy of the NCSC/CSCI guidance on “The Immediate Administration of Prescribed Medication by Specialised Techniques” was provided during the inspection. There were currently no medicines administered in the home within this guidance. A written procedure is required, as By 23 discussed, for the doses of medicines taken February out of the home for service users who may 2006 leave the home for brief periods of unplanned leave, e.g. day-care, outings, etc. Hart Lodge DS0000059918.V282415.R01.S.doc Version 5.1 Page 18 Item code/ References S. 2) 5.1 3) Appendix 4 T. 2) 7.0 U. 2) 2.0 2) 5.1 In order to deal effectively with any blood spillage and avoid the risk of cross-contamination of blood-borne micro organisms e.g. Hepatitis, a policy and procedure is required and the home is to keep a stock of sodium dichloroisocyanurate granules (Presept or equivalent) as described in the Department of Health policy provided. A guide policy and procedure for the stock control of liquid medicines was given to the home’s manager during the inspection. This refers to the in-use shelf life and in particular those infrequently used e.g. when required dosing. Unless stated otherwise, clear liquids should be discarded after six months and particulate liquids, e.g. suspensions, three months. The good practice of entering the date of first opening should be applied to any medicine where usage may go beyond the in-use shelf life. A written policy/procedure is required for the handling of cytotoxic medicines. A draft policy/procedure was provided during the inspection. There were currently no medicines within this category in the home. A wound care policy/procedure should be available providing guidance for staff on the action required according to the severity of an injury. The home’s existing policy on First Aid may be expanded to serve this purpose. Timescale for action Immediate Immediate V. 2) 2.0 By 23 April 2006 or on receipt of any cytotoxic medicines, whichever is sooner By 23 April 2006 Hart Lodge DS0000059918.V282415.R01.S.doc Version 5.1 Page 19 Item code/ References W. 2) 5.2 X. 2) 5.2 A maximum/minimum thermometer is required to monitor the fridge temperatures when medicines require cold storage. Details of suitable thermometers have been provided at the time of the inspection. There were currently no medicines requiring cold storage and the fridge appeared to be operating satisfactorily at the time of the inspection. The temperature records for the cold storage of medicines are to include the daily monitoring of the maximum and minimum temperatures in addition to the current reading. An example of a suitable temperature record chart was provided during the inspection. The home’s policy/procedure for medicines requiring cold storage requires reference to the temperature monitoring requirements. A draft policy/procedure was provided at the time of the inspection. Medicine policies and procedures are to be updated and consolidated to include the additions and changes occasioned by implementation of the above points, as discussed. This should include the documented information provided during the inspection. Timescale for action By 23 April 2006 or on receipt of any medicines requiring cold storage, whichever is sooner By 23 April 2006 or on receipt of any medicines requiring cold storage, whichever is sooner By 23 April 2006 or on receipt of any medicines requiring cold storage, whichever is sooner By 23 April 2006 Y. 2) 2.0 Z. 2) 2.0 The pharmacist inspector will be revisiting the home to review compliance with the above requirements and recommendations. Hart Lodge DS0000059918.V282415.R01.S.doc Version 5.1 Page 20 No. References 1) National Minimum Standards (NMS) in care homes for younger adults. A statement of national minimum standards published by the Secretary of State for Health under section 23(1) of the Care Standards Act 2000. Department of Health. 2) The Administration and Control of Medicines in Care Homes and Children’s Services. Royal Pharmaceutical Society of Great Britain - June 2003. 3) Guidelines on the Control of Infection in [Care] Homes. Department of Health – 1996 Hart Lodge DS0000059918.V282415.R01.S.doc Version 5.1 Page 21 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): EVIDENCE: At the previous inspection all standards in this section were assessed as met and were not assessed again as part of this inspection. The manager however advised the inspector that a number of issues had been raised by a relative of one of the service users but none of these were recorded. The manager said this was because they had not put in a formal complaint. The registered person is required to ensure that any issue, which relates to the quality of care is clearly recorded in the complaints record including the action taken to resolve this issue. Hart Lodge DS0000059918.V282415.R01.S.doc Version 5.1 Page 22 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 &30 Service users benefit from a well-maintained, safe, well-furnished and pleasant place to live. EVIDENCE: Hart Lodge DS0000059918.V282415.R01.S.doc Version 5.1 Page 23 The home was registered within the two years and meets the national minimum standards. The home is supported by well-serviced transport links to central Romford’s extensive shopping and leisure facilities. All service users are provided with a single lockable room and a lockable facility within that room. Bedrooms were furnished according to the wishes of the service user. The building was well decorated furnished and maintained. A leak had occurred in an upstairs room which had caused damage to the lounge ceiling. At the time of the inspection this was still drying out and the inspector was advised that this would be repaired within the following month once it had dried out. The building is accessible for people with limited mobility and is provided with some ground floor bedrooms and a shower however would not suit wheelchair users. The building meets all requirements of fire prevention and environmental health. The home is building a new office area to the front of the building in order to provide additional space for staff meetings and training. The homes phone has since the last inspection been locked with the agreement of all service users due to an ongoing care issue relating to one service user. However during this inspection one service user said the current arrangements although agreed at the time was not working effectively. It is recommended that the home place this on the agenda for discussion at the next service user meeting. The garden area was a pleasant landscape designed decked area with plants to enhance it. No special adaptations were required for the client group. The premises were clean, hygienic and odour free. Residents said that the home was nice and they were happy with the facilities on offer. One service user again raised the issue of the feeling that the kitchen does not effectively meet the needs of everyone living in the home as staff cook for some service users but a large preparation of residents cook their own food. The kitchen arrangements according to residents do not meet the needs all people living in the home as it can get extremely cramped. Staff refuted this and said that service users are encouraged to take turns. It is strongly recommended that the registered persons review current catering arrangements and facilities in partnership with the service users. Hart Lodge DS0000059918.V282415.R01.S.doc Version 5.1 Page 24 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): 33,34,35 &36 Service users are protected by the homes recruitment procedures. Staff benefit from systems of support and training. EVIDENCE: Staff recruitment records were checked on two staff files and were in line with statutory requirements. New staff had an initial induction supported by a further in depth TOPPS induction process. All staff serve a probationary period of six months at the end of which it is confirmed in writing whether this is completed or to be extended. Staff supervisions systems were in place with eth two staff files samples recording regular supervision taking place. Staff meetings were held regularly with over six taking place in the last twelve months however no staff meeting had been held since October. It is recommended that no more than two months gap occurs between staff meetings. Staff interviewed said they had benefited from training in the administration of medication and all were in the process of completing their NVQ training. New staff do not have to fund this training themselves but older serving staff originally self funded this training. Staff advised that the home has agreed to remorse all staff who self funded their NVQ training. It is recommended that a staff training profile be developed for each member of staff and the staff team as a whole. Hart Lodge DS0000059918.V282415.R01.S.doc Version 5.1 Page 25 Hart Lodge DS0000059918.V282415.R01.S.doc Version 5.1 Page 26 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 &42 The building is maintained in a safe condition and systems are in place to ensure the health and safety of service users and staff. Service users and staff benefit from an open management style within the home. Service users views underpin the quality monitoring within the home. EVIDENCE: The manager is a Registered mental Nurse who has experience of managing a forensic psychiatry ward. This is the manager’s first community post. The manager has within the past year been registered by the Commission and found to be a “fit person”. As the manager has no management qualification but is to begin his Registered managers Award in April. Cleaning chemicals were noted to be stored in the kitchen within easy reach of anyone who intentionally or accidentally could harm himself or herself. The registered person is required to ensure that harmful substances are stored in a locked area. Hart Lodge DS0000059918.V282415.R01.S.doc Version 5.1 Page 27 Part of the complaint received by the Commission related to the openness and supportiveness of the management of the home. The inspector spent time talking with staff on duty and service users to find out how they viewed the management of the home. Service user meetings were held regularly with at least six taking place over the year. The last one held however was some three months previously. The meetings are chaired by a service user and staff take the minutes. The service user who chairs the meetings said they felt that they were a useful forum to discuss issues and the at the proprietors took on board issues that were raised and tried to sort out any concerns. Staff and service users said that they found the management of the home to be open and supportive. Staff gave examples such as recent employment and contractual issues being discussed with the owners who listened and acted upon the staffs comments regarding contracts and salaries. Staff said that the registered persons visited the home regularly and spoke with staff and asked their opinions on matters. Staff said they felt well supported able to discuss any matters with the manager and homeowners. Staff said they felt the home and management as a whole to be a fair employer. Service suers gave similar comments by saying that all the staff, manager and homeowners were happy to talk to them and they would listen to any issues raised. The registered persons arrange an independent person to visit the home monthly and undertake a review of the quality of the home in line with regulation 26 a copy of this report is given to the home and a copy sent to the commission. Hart Lodge DS0000059918.V282415.R01.S.doc Version 5.1 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 3 X 4 X 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 x ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 X 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 x LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 x 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x 2 2 x 3 3 3 X X 2 x Hart Lodge DS0000059918.V282415.R01.S.doc Version 5.1 Page 29 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 15 Requirement The registered person is required to ensure that care plans are reviewed and updated regularly and at least six monthly The registered person is required to ensure that risk assessments are reviewed and updated on a regular basis. The registered person is required to ensure that self-medicating service users have this clearly identified and supported by a care plan. The registered person is required to ensure that all requirements and recommendations in the pharmacists report are met. The registered person is required to ensure that any issue, which relates to the quality of care is clearly recorded in the complaints record including the action taken to resolve this issue. The registered person is required to ensure that harmful substances are stored in a locked area. Timescale for action 01/04/06 2 YA9 15 01/04/06 3 YA9 13 01/04/06 4 YA20 13 01/04/06 5 YA22 22 01/04/06 6 YA42 13 01/04/06 Hart Lodge DS0000059918.V282415.R01.S.doc Version 5.1 Page 30 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 3 4 5 6 7 8 Refer to Standard YA17 YA35 YA37 YA19 YA19 YA24 YA24 YA36 Good Practice Recommendations It is strongly recommended that the cooking arrangements be discussed at a service users meeting and possible solutions examined. It is recommended that a staff training profile be developed for each member of staff and the staff team as a whole. As the manager has no management qualification it is strongly recommended that he undertake management training to NVQ 4 level. it is recommended that a referral to the dietician be made for these service users in order to ensure correct dietary advice for their specific needs is given. it is recommended that the home consider the use of a health care monitoring record. It is recommended that the home place the access to the residents phone on the agenda for discussion at the next service user meeting. It is strongly recommended that the registered persons review current catering arrangements and facilities in partnership with the service users. It is recommended that no more than two months gap occurs between staff meetings. Hart Lodge DS0000059918.V282415.R01.S.doc Version 5.1 Page 31 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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 Hart Lodge DS0000059918.V282415.R01.S.doc Version 5.1 Page 32 - 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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