Inspection on 10/06/05 for Herons Lodge

This inspection was carried out on 10th 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 but made no statutory requirements on the home.

Other inspections for this house

Herons Lodge 11/08/09

Herons Lodge 27/05/09

Herons Lodge 07/07/08

Herons Lodge 07/06/06

Herons Lodge 10/01/06

Herons Lodge 18/10/04

Herons Lodge 26/05/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Herons Lodge 138 Northampton Road Market Harborough Leicestershire LE16 9HF Lead Inspector Moira Mosley Unannounced 10 June 2005 10.00 th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Herons Lodge C51 S35094 Herons Lodge V232399 100605 Stage 2.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Herons Lodge Address 138 Northampton Road Market Harborough Leicestershire LE16 9HF 01159 859517 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) Mentaur Ltd Vacant Care Home 10 Category(ies) of LD Learning Disability (10) registration, with number MD Mental Disorder (10) of places Herons Lodge C51 S35094 Herons Lodge V232399 100605 Stage 2.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. No one falling with category MD may be admitted to the home unless that person also falls within category LD, ie dual disability. Date of last inspection 18th October 2004 Brief Description of the Service: Herons Lodge is a care home providing personal care and accommodation for ten young adults with learning disabilities. The premise is owned by Mentaur Limited, operators of a number of care homes in the Midlands. The home is located close to the town centre of Market Harborough where service users have access to shops, pubs, the post office and other amenities. The home is easily accessible by private or public transport. There are a range of facilities including two lounge areas and a dining room for communal use. The premise is a converted property with two floors and access to the first floor is by use of the stairs. There is level entry access to the home. There are ten single bedrooms, nine without en-suite facilities. The home has a garden to the rear of the building which is well maintained and which is accessible to all service users residing on the premise. Herons Lodge C51 S35094 Herons Lodge V232399 100605 Stage 2.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This statutory unannounced inspection was undertaken as the result of an anonymous complaint; 2 hours were spent gathering information and planning for the inspection and 5.5 hours were spent in the home. The care of two service users was reviewed to include their care plans, medication and other records. Four service users were in the home. Due to their learning disability some were unable to comment on their care however a period of observation and discussion with two of the service users was undertaken along with discussions with 2 staff members to ascertain how care is provided. A staff member who was not on duty at the time of the inspection telephoned to add comments and concerns following the inspection. What the service does well: What has improved since the last inspection? Service user healthcare is being managed well with evidence of support and input from a range of professionals including the GP and the community learning disability team. Staff have all received training about abuse and how to report any concerns through the Protection of Vulnerable Adults procedures. Herons Lodge C51 S35094 Herons Lodge V232399 100605 Stage 2.doc Version 1.30 Page 6 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. Herons Lodge C51 S35094 Herons Lodge V232399 100605 Stage 2.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Herons Lodge C51 S35094 Herons Lodge V232399 100605 Stage 2.doc Version 1.30 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 standard(s) These standards were not assessed on this inspection. EVIDENCE: Herons Lodge C51 S35094 Herons Lodge V232399 100605 Stage 2.doc Version 1.30 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 standard(s) 6, 7 and 9 The service users are at risk of not having their needs met due to the lack of care plans and risk assessments. EVIDENCE: Care plans were not up to date with no evidence of recent review. There were a large number of aggressive incidents recorded for two of the service users without evidence of risk assessments documentation to demonstrate measures put in place to minimise the risk. Risk assessments that were in place had not been reviewed for several months. Staff spoken to were clear on how they managed the situation and levels of observation needed however this was not recorded and consistency of approach could not be demonstrated. There were some very detailed care plans that gave clear concise direction for staff to follow, however these were ‘lost’ in the huge amount of documentation within the notes and although they stated to be reviewed monthly most had not been reviewed since October 2004. Herons Lodge C51 S35094 Herons Lodge V232399 100605 Stage 2.doc Version 1.30 Page 10 The acting manager provided the new care plan format that would address these issues and they are working to have these as active documents within the next few weeks. There was evidence of both service user and their representatives agreement to care plans and the 2 service users who were able to speak with the inspector were aware of their plans and any restrictions placed on them, for example in regard to smoking were documented and agreed. There was one service user who has been displaying a high incidence of aggressive outbursts and targeting another service user when he is upset. There are plans in place to minimise the risk, which include 1-1 sessions with staff however the rota and staff spoken to confirmed this is not happening due to the lack of consistent staffing in adequate numbers to meet the service users needs. Herons Lodge C51 S35094 Herons Lodge V232399 100605 Stage 2.doc Version 1.30 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 standard(s) 12, 13, 14, 16 and 17 The lack of suitably qualified and experienced staff is severely restricting the service users from receiving a quality service and this is impacting on their behaviours. EVIDENCE: The service users have individualised programmes of daily activities. Three do not attend any formal day care or college facility and these have programmes for staff to implement on a daily basis. As identified within the staffing standards the home currently do not have sufficient regular staff to meet all the service users needs. One service user identified as having a 1-1 evening session that has a rota of staff coverage is not having this provided. This was agreed to be in place to reduce the risk of aggressive outbursts and the levels of incidents has increased. Herons Lodge C51 S35094 Herons Lodge V232399 100605 Stage 2.doc Version 1.30 Page 12 It was evident that at weekends and evenings the staff often cannot provide the outings and activities planned due to staffing levels, availability of drivers and agency staff being used who cannot be left with service users. One service user has been unable to have a home visit facilitated as planned due to the same issues. The service users spoken to said the staff “are brilliant” and they “are nice and take care of us”. The two service users who could express themselves were more able to occupy themselves and had a level of freedom including unescorted leave in the community. They were unable to comment on how the others who were less able spent their time. The service users said the food was good and menus are planned with service user involvement on a weekly basis. The care staff also do the shopping for food and all meal preparation. Herons Lodge C51 S35094 Herons Lodge V232399 100605 Stage 2.doc Version 1.30 Page 13 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 Service user healthcare needs are being fully assessed and being met with appropriate interventions. Medication records are insufficient to demonstrate that the ordering of service users medication is being managed effectively. EVIDENCE: Service users have access to healthcare services including the GP, optical and podiatry services. In addition they have all been registered and had involvement from the learning disability community services including the community nurse and where required the CPA (Community Programme Approach) has been implemented with evidence of recent reviews. Service users health is monitored including regular weighing with plans in place for any concerns raised. The recording of all the service users dietary intake was discussed, as it appeared to be a process with no evidence or reason for recording and these were not being monitored, the acting manager agreed to review this process. The service users spoken to confirmed they receive support for personal care and were able to make choices in regard to their level of need. They said they were able to make choices for example when they went to bed and got up in the morning. Herons Lodge C51 S35094 Herons Lodge V232399 100605 Stage 2.doc Version 1.30 Page 14 Staff spoken to were very positive about how they were able to encourage and support independence skills and one service user discussed has made great progress in her levels of interaction, choice and independence in the past few months. The medication cross referenced to the medication administration records and there are systems in place to ensure the safe administration of medication, however there was no clear audit system of the totals of medication held in the home for each service user and one service user had insufficient liquid medication available until the next order was due, this was addressed by the acting manager. Herons Lodge C51 S35094 Herons Lodge V232399 100605 Stage 2.doc Version 1.30 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 The complaints procedure needs to be reviewed to ensure service users are clear on how complaints will be dealt with. There is an effective system in place to deal with complaints and with vulnerable adult issues. Service users are at increased risk of harm due to the staffing problems within the home. EVIDENCE: There is a complaints procedure on the communal notice boards written in a service user-friendly format. However the complaints procedure within the statement of purpose, service user guide and in the policy file does not contain sufficient information about how complaints are dealt with when received and what timescales will be implemented. An anonymous complaint was received by the Commission for Social Care Inspection (CSCI) raising concerns about the treatment of the service users by staff, the levels of aggression between service users resulting in bruising and an allegation of sexual abuse that was not addressed by the company. There are a number of incidents between service users and as indicated within standards 6-10 the risk assessments are not fully up to date however incident and accident records are being maintained and regular reviews have been implemented with planned interventions to reduce the risk. These planned interventions are not being made due to the staffing issues and this is seriously impacting on the homes ability to protect the service users. Herons Lodge C51 S35094 Herons Lodge V232399 100605 Stage 2.doc Version 1.30 Page 16 There has been a recent Protection of Vulnerable Adults (POVA) investigation into an allegation of inappropriate behaviour by a staff member and this has been conducted in liaison with the Leicester POVA team and the CSCI. The allegation was not founded and appropriate staff management and training has been put in place. The service users spoken to stated they had no concerns about staff in the home and were very positive about their care. Staff spoken to had received training on abuse and were clear about how to report any concerns. Herons Lodge C51 S35094 Herons Lodge V232399 100605 Stage 2.doc Version 1.30 Page 17 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) These standards were not assessed on this inspection. EVIDENCE: These standards were not fully addressed however it was evident that there has been recent redecoration to the communal lounge and there is a planned redecoration and renewal programme for the home. The service users said they were very happy with the facilities and liked their bedrooms. Herons Lodge C51 S35094 Herons Lodge V232399 100605 Stage 2.doc Version 1.30 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 and 35 Staff morale is low resulting in high staff turnover and poor attendance, which in turn is severely impacting on the quality of care received by the service users. EVIDENCE: The rotas showed that the number of staff on duty was maintained however there is a high dependency on agency staff. There has been a high turnover of staff and sickness levels. Staff spoken to were unhappy with the expectation for them to work excessive hours and long shifts. On the day of the inspection the senior carer found she was going to have to work over her shift due to sickness and this was reported as a regular occurrence. A staff member who was not on duty at the time of the visit telephoned the inspector after the inspection to raise concerns about staffing and the low morale amongst the few remaining staff members. It was identified that 2 service users were being funded for extra support at key periods to assist in occupying them and to minimise the levels of Herons Lodge C51 S35094 Herons Lodge V232399 100605 Stage 2.doc Version 1.30 Page 19 aggression and incidents. This was not being provided due to lack of experienced staff to carry out these duties. There is a lack of drivers available for shifts which impacts on the level of activities and outings that are provided for the service users. In addition to providing care for the service users staff have to prepare all meals and undertake some cleaning duties. There was no evidence to demonstrate that staffing levels account for the dependency needs of the service users or for the other duties outside care required. There is a comprehensive training programme provided by the company, which provides a wide range of training opportunities. Staff spoke about the difficulty in attendance for training, due to providing cover at the home and it added extra pressure to what was described as ‘crisis management’ of the home at this time. Herons Lodge C51 S35094 Herons Lodge V232399 100605 Stage 2.doc Version 1.30 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 and 42 Service users are involved in decision-making and their health and safety is maintained. EVIDENCE: There is a service user questionnaire that forms the basis of a quality audit of the services provided in the home and the results are published with an action plan to address any issues raised. A staff satisfaction questionnaire has just been sent out to gain staff views about the home. The service users stated there are regular service user meetings and they have the opportunity to be involved in decisions made. Staff spoken to confirmed they receive statutory training including fire, manual handling and food hygiene. There was health and safety guidance including COSHH (control of substances hazardous to health) legislation information available within the home. Herons Lodge C51 S35094 Herons Lodge V232399 100605 Stage 2.doc Version 1.30 Page 21 Accident and incident reports are recorded and reviewed regularly to assess and minimise risk areas. Herons Lodge C51 S35094 Herons Lodge V232399 100605 Stage 2.doc Version 1.30 Page 22 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 x x x Standard No 22 23 ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 1 3 x 1 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x x Standard No 11 12 13 14 15 16 17 x 3 2 2 x 3 3 Standard No 31 32 33 34 35 36 Score x x 1 x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Herons Lodge Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 3 x C51 S35094 Herons Lodge V232399 100605 Stage 2.doc Version 1.30 Page 23 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 6 Regulation 12(1)(a) and (b) 13(4)(c) and 17(3)(a) 15, 17(3)(a) Requirement Care plans must reflect the assessed and current needs of the service user and detail the actions required of staff. (previous timescale of 25/10/04 not met) Care plans must be regularly reviewed dated and signed to ensure accuracy of content.(previous timescale of 25/10/04 not met) Risk assessments must be in place for any identified risk including aggression. Arrangements must be made to provide service users with activities, social and community access as identified within service user agreed plans. A clear audit trail of all medication in the home must be maintained. Staffing levels must be calculated and demonstrated to account for service user dependency levels and required levels of support to manage aggression. A management plan for the recruitment and retention of staff to meet the service users Timescale for action 30/08/05 2. 6 30/08/05 3. 4. 9 13 and 14 12(1)(a) and (b) 13(4)(c ) 16(2)(m)( n) 30/08/05 30/08/05 5. 6. 20 33 13(2) 18(1) 12(1)(a) 10/08/05 30/08/05 7. 33 18(1) 10/07/05 Herons Lodge C51 S35094 Herons Lodge V232399 100605 Stage 2.doc Version 1.30 Page 24 needs must be submitted to the CSCI. 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 22 Good Practice Recommendations The complaints procedure should include details of how the complaint will be dealt with and the timescales. Herons Lodge C51 S35094 Herons Lodge V232399 100605 Stage 2.doc Version 1.30 Page 25 Commission for Social Care Inspection 1st Floor, Newland House Campbell Square Northampton NN1 3EB 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 Herons Lodge C51 S35094 Herons Lodge V232399 100605 Stage 2.doc Version 1.30 Page 26 - 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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