Inspection on 27/05/09 for Herons Lodge

This inspection was carried out on 27th May 2009.

CQC found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Herons Lodge 11/08/09

Herons Lodge 07/07/08

Herons Lodge 07/06/06

Herons Lodge 10/01/06

Herons Lodge 10/06/05

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 06/08/2009.

Key inspection report Care homes for adults (18-65 years) Name: Address: Herons Lodge 138 Northampton Road Market Harborough Leicestershire LE16 9HF The quality rating for this care home is: one star adequate service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Ruth Wood Date: 2 8 0 5 2 0 0 9 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should:  Be safe  Have the right outcomes, including clinical outcomes  Be a good experience for the people that use it  Help prevent illness, and promote healthy, independent living  Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home:  3 stars – excellent  2 stars – good  1 star – adequate  0 star – poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area Outcome area (for example: Choice of home) These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement Care Homes for Adults (18-65 years) Page 2 of 36 Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by:  Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice  Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983  Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services.  Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 36 Information about the care home Name of care home: Address: Herons Lodge 138 Northampton Road Market Harborough Leicestershire LE16 9HF 01858465441 01858465441 lucikad@yahoo.co.uk www.mentauruk.com Mentaur Limited care home 10 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 Over 65 10 10 0 0 learning disability mental disorder, excluding learning disability or dementia Additional conditions: The maximum number of service users who can be accommodated is 10. The registered persons may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission are within the following category: Learning disability - Code LD Mental disorder - Code MD. Date of last inspection 0 7 0 7 2 0 0 8 Care Homes for Adults (18-65 years) Page 4 of 36 A bit about the care home Herons Lodge is a care home for people with learning disabilities or mental health problems. Ten people can live at the home. It is close to the town centre of Market Harborough. There are shops, pubs, restaurants and a post office in Market Harborough. There are two lounge areas and a dining room on the ground floor. Each person in the home has their own bedroom. There are bedrooms on the first and second floors. You can get to the bedrooms using the stairs. One bedroom has a toilet and shower. The home has a garden. It costs between £700 and £2,000 a week to live at the home. People pay extra for hairdressing, clothes, toiletries and holidays. The service users guide tells people about the services in the home. Care Homes for Adults (18-65 years) Page 5 of 36 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home Care Homes for Adults (18-65 years) Page 6 of 36 How we did our inspection: This is what the inspector did when they were at the care home Before we visited the home we looked at the information that the people who own the home had sent us about how the home is run and the kind of people who live and work there. We looked at information that the manager had sent us about things that had happened in the home since our last visit. We looked at the replies to our surveys. These gave us some information about what people think about living and working in the home. We have put some of this information in the report. We visited the home on 27th May 2009 for 7 hours and on 28th May 2009 for 3 hours. We looked at all the rooms in the house. Care Homes for Adults (18-65 years) Page 7 of 36 We watched how staff get on with and support people living in the home. We spoke to some people living in the home about what they had done during the day. We looked at peoples support plans and how their needs are met. We spoke to staff about how they supported people and about the training they had done. We looked at staff records that told us about the checks that had been done to make sure people had the right skills and were safe to work in the home. Care Homes for Adults (18-65 years) Page 8 of 36 What the care home does well . Peoples health care needs are met. Staff support people to visit the doctor, dentist and optician. People can take part in cooking their own food and helping to keep their rooms clean and tidy People are helped to make choices about their lives. They have regular meetings to decide things about the home such as what kind of food to cook. Care Homes for Adults (18-65 years) Page 9 of 36 What has got better from the last inspection There are new cabinets to store medication in. Information about how to make a complaint has been improved. The dining room has been redecorated and has new furniture. Some peoples rooms have been redecorated. What the care home could do better Care Homes for Adults (18-65 years) Page 10 of 36 Private information about people living in the home should be locked away safely. People should be given the choice to have their own bank accounts. Some staff need training about how to work with people with learning disabilities and mental health problems. The home needs more staff so that people who live in the home can have all their needs met. The manager should be given more time to manage the home and support staff. She spends too much time working as a member of staff. Care Homes for Adults (18-65 years) Page 11 of 36 The bathrooms need better heating that is safe and will not burn people. If you want to read the full report of our inspection please ask the person in charge of the care home If you want to speak to the inspector please contact Ruth Wood CPC1 Capital Park Fulbourn Cambridge Cambridgeshire CB21 5XE 01223771300 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You Care Homes for Adults (18-65 years) Page 12 of 36 can get printed copies from enquiries@cqc.org.uk or by telephoning our order line - 0870 240 7535. Care Homes for Adults (18-65 years) Page 13 of 36 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 14 of 36 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Some information in the service users guide isnt accurate. This makes it harder for people to make an informed decision about whether they want to live at Herons Lodge. Peoples needs are assessed before they move into the home to make sure that they can be met. Evidence: The service user guide is written with pictures to help people understand the information. The service could look at other ways of presenting the information, to make sure that all the people living in the home can understand it. Some of the information in the service users guide is inaccurate and should be changed. The contact details for the safeguarding team should be changed from Northamptonshire to Leicestershire, as this is where the home is situated. The guide also states that people living in the home, will be encouraged to help to interview staff to work at Herons Lodge. There is no evidence that service users have been involved in interviewing staff since the last key inspection, despite several new staff appointments. This statement should therefore be removed from the guide. Care Homes for Adults (18-65 years) Page 15 of 36 Evidence: There have been no new admissions to the home since the previous key inspection when we observed that peoples needs had been assessed before they moved into the home. There is evidence that support plans have been modified, to reflect peoples changing needs. Care Homes for Adults (18-65 years) Page 16 of 36 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Support plans outline how peoples needs should be met and how risks should be managed. Peoples choices are sometimes limited by the level of staff on duty. Evidence: We looked at four peoples support plans. There is evidence that these are reviewed and updated as peoples needs change. For example changes had been made to one persons plan who had recently been discharged from hospital. Some people have special plans and risk assessments in place to monitor some of their behaviour, which may be challenging. Some of this information is shared with outside professionals so that they can suggest additional ways to support the person. Some people have support from one staff member at certain times during the week. One persons one to one support is clearly recorded and one staff member consistently provides this. The one to one support that another person should receive on a Saturday is not clearly recorded, so it is difficult to assess whether the person is receiving this on a regular basis. Care Homes for Adults (18-65 years) Page 17 of 36 Evidence: There is a weekly residents meeting so that people can make decisions about the sort of food that they eat at the home and the kinds of things that they would like to do. Sometimes peoples choices about what they do during the day are restricted because of insufficient staff cover. On the first day of the inspection, one person was unable to attend a day placement because there were insufficient staff. Another person at the home does not have a day placement. Both people were being supported by the acting manager, who because of other duties was unable to offer any structured activity for them. Information about advocacy services is displayed in the home and the manager had previously sought an advocate for one person, to deal with a specific decision they had been asked to make. Robust systems are in place to make sure that peoples monies are looked after safely however all peoples monies are held in an umbrella account, managed by the organisation who owns the home. This makes it difficult for people to have any real concept or understanding of where their money is coming from, or to have any real independence in managing it. It is recommended therefore that consideration be given to each individual having their own separate bank account. The service is working to balance the different needs of people living in the home. Some people living in the home require a high degree of staff input, to ensure that they do not present a risk to themselves or to the people they live with. Risk assessments have been put in place, in response to incidents that have taken place in the home. These outline the response staff should make to any behaviour that may challenge. Managing the risks associated with one person requires a high degree of staff input, which can impact on the staff available for other people living in the home. Care Homes for Adults (18-65 years) Page 18 of 36 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Some peoples lifestyle is limited because of insufficient staffing levels. People receive food which is appropriate to their cultural needs and they can eat in pleasant surroundings. Evidence: Six people attend formal, specialist day care; two at a day centre run by the local authority, the remainder attending a centre run by Mentaur (the people who run the home.) Some people are supported by staff who work in the home when they attend these centres. One person does not have any regular day time activity and on the day of the inspection was following the acting manager, as she performed her administrative duties. One person, who should have attended the organisations day centre, was unable to do so as there were no staff available to support or take them there. This person has an individual activity plan, which includes one session when they are supported to attend an Care Homes for Adults (18-65 years) Page 19 of 36 Evidence: aerobics class. They also have daily two hour sessions of time when they are watching television with friends or listening to music. Looking at their timetable, and from direct observation during the two days of the inspection, this person appears to spend a large part of each day in unstructured activity, without direct staff support. The acting manager said that they had not managed to find suitable activities for this person yet but they are looking into ways of finding these. One person, whose support that we looked at in detail, has one to one support during weekday mornings and goes out with a staff member shopping or to a cafe. Staff members supported some people to attend a special disco for people with learning disabilities in Leicester on the evening of the first day of the inspection. People are also supported to go shopping and to go to local cafes. Two people in the home are supported by staff to go swimming. There were insufficient staff to enable people to go on holiday last year but the acting manager has put together plans for people to go on holiday this year. She is waiting for her manager at the organisations head office to approve these plans before she can book the holidays. People help to choose what they eat at the home and each persons daily diet is recorded individually. It is recommended that what people eat to accompany main meals (such as vegetables or salad) is also recorded, to evidence that people are receiving a balanced diet. On the day of the inspection the main meal (served in the evening) was lasagne, which had been freshly made using minced lamb so that it could be eaten by all people living in the home, including the person who does not eat pork or beef for cultural reasons. On the second day of the inspection we saw that people are encouraged to take part in preparing and cooking their meals. The dining room has recently been redecorated and is a pleasant place to eat. Care Homes for Adults (18-65 years) Page 20 of 36 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples health, personal care and medication needs are met. Evidence: The four peoples support plans we looked at contained evidence that people have regular access to a variety of health care services, such as GPs, dentists, podiatrists and opticians. One person was supported by staff to attend the dentist on the first day of the inspection. People are supported to access support from consultant psychiatrists and community nurses and have access to annual health checks and medication reviews. The Commission was informed of a medication error in August of last year and the service put measures in place to ensure that practice in this area improved. In January 2009 three current staff members received training in medication handling and currently only the manager and senior staff members administer medication. Clear protocols are in place for those people taking as required medication and this is stored separately. All medication is stored securely and appropriately and Medication Administration Records (MAR) seen were accurately completed. Peoples personal care needs are outlined in their care plans and specific needs in relation to their culture and ethnicity are also addressed. Care Homes for Adults (18-65 years) Page 21 of 36 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Responses to challenging behaviour currently ensure peoples immediate safety Evidence: The complaints procedure is available in a pictorial format and is displayed on the office notice board. There are weekly residents meetings, which give an opportunity for those able, to express their concerns. For those people living in the home who do not have well developed, formal methods of communication it should be clearly noted within their support plans how they express their unhappiness or displeasure and how staff should respond to this. Staff confirmed that they had received training in safeguarding vulnerable adults and that they knew what action to take if they suspected or witnessed abuse taking place in the home. Five safeguarding referrals have been made to the local authority since the previous key inspection; three of these have been resolved and two are still to be addressed. Seven staff received initial or refresher training in Non-Abusive Psychological and Physical Intervention (NAPPI) in December 2008 and staff confirmed that they regularly use the techniques they had learned, particularly when working with one of the people living in the home. Concerns have been expressed about the danger that this person has posed to other people living in the home because of their behaviour. Strategies appear to be in place to keep people safe, but these rely heavily on the administration of as required medication and require high levels of staff input. This can detract from the support Care Homes for Adults (18-65 years) Page 22 of 36 Evidence: required by other, less immediately challenging people, who live in the home. Care Homes for Adults (18-65 years) Page 23 of 36 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is clean and peoples bedrooms reflect their individual tastes and personalities. Bath and shower rooms need improvement so that people can wash safely and in comfort. Evidence: The dining room has recently been redecorated and this area appeared fresh, clean and comfortable. Several peoples bedrooms have been redecorated and carpets replaced by laminate flooring. The acting manager said that one persons bedroom carpet was due to be cleaned at the end of the week. We asked the manager to move one persons extension socket as it was directly beneath their wash basin. Improvements are needed to the bath and shower rooms in the home to ensure that people can bathe and shower safely, comfortably and have their dignity maintained. All the bath and shower rooms require suitable window coverings to ensure that people can use them without being seen by people outside of the home. The manager said that the shower room on the top floor of the home has been out of commission since she started work there in August 2008, despite there being two service users bedrooms on this floor, one of which is currently occupied. The shower room has black mould on the wall, under the window, and the only form of heating in the room is an uncovered heated towel rail which is located directly next to the toilet and Care Homes for Adults (18-65 years) Page 24 of 36 Evidence: would be a burning risk if switched on. One first floor bathroom is currently being refurbished; the radiator in this room is currently disconnected but has never been covered and as such, when re-connected will present a burning risk. The only source of heating in the green shower room is an uncovered heated towel rail. When switched on this presents a risk of burning. On both days of the inspection the home was clean and tidy and there were no unpleasant smells. Care Homes for Adults (18-65 years) Page 25 of 36 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Not all staff have the necessary training or experience to meet peoples needs, neither are current staffing levels always sufficient to meet peoples needs Evidence: As has been stated in earlier outcome groups, some peoples choices and activities are limited because there are insufficient staff on duty at all times to meet peoples needs as well as manage the challenges presented by one service user. The acting manager is also expected to work as a member of staff within the home and directly support service users. On the first day of the inspection we observed that she was directly responsible for two service users (both requiring a high degree of structured input) but at the same time was expected to respond to telephone calls and to carry out administrative duties. This lack of management time also compromises her ability to fulfil the expectations of Mentaurs supervision contract. Staff should receive formal one to one supervision every six weeks but there was no recorded evidence that this is taking place for all staff. The manager said that she tried to meet with staff but often did not have the time to formally record any meetings. Staff spoken to on the day of the inspection said that they felt that the manager did support them in their work. We were given a copy of the rota for the week during which the inspection took place and noted that staff members were working long hours. One new staff member was allocated Care Homes for Adults (18-65 years) Page 26 of 36 Evidence: to work 59 hours during this week, including two days when they would work fourteen and half hours. Given the complexity of need of the people living in the home and the behavioural challenges that they sometimes exhibit, the registered persons should consider whether such extended working hours compromises the quality of care that people receive. We looked at the recruitment records of three people recently employed to work in the home. These contained evidence of identity, two written references, a record of previous employment and evidence that Criminal Records Bureau checks had been undertaken. The date that peoples names had been checked against the vulnerable adults register was handwritten on the persons file. Verifiable evidence that this check has been completed must be available for inspection. Staff members spoken with confirmed that they had received statutory required training in such areas as first aid, fire safety and infection control. They said that they had also received training in safeguarding vulnerable adults, non-abusive psychological and physical intervention (NAPPI) and how to work with people with autism. The majority of training is provided by the parent organisation Mentaur, at their head office. It was difficult to verify staff training as staff do not hold their own training certificates, neither are copies of these placed on the staff files held in the home. Verifiable evidence of staff training should be available at the home for inspection. Three recently employed staff members that we spoke to have no previous experience of working with people with learning disabilities or with mental disorder. All members of staff should receive appropriate training in working with the categories of people for which the home is registered so that they are able to meet peoples needs. Positive interaction was observed between the people living in the home and the established staff members working there, who they had developed and built a relationship with. Care Homes for Adults (18-65 years) Page 27 of 36 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The acting manager does not have sufficient time or autonomy to manage the home so that it is consistently run in the best interests of the people who live there. Evidence: The service has not had a registered manager since August 2008. We wrote to the owners of the service, Mentaur in January 2009 reminding them that it is an offence under the Care Standards Act 2000 and Regulation 8 of the Care Home Regulations 2001, to carry on or manage a Care Home without registration and asking when they would submit an application for registration. We have received no response to this letter. The acting manager has been in post since August 2008 and holds a National Vocational Qualification (NVQ) in care at level 3 and has enrolled herself for an NVQ qualification in leadership and management. During the inspection she said that she intended to submit her application for registration but this has not yet been received. As outlined in earlier outcome groups the managers ability to effectively manage the service is compromised because she does not have sufficient time allocated, solely for management and support of staff. Additionally neither she (nor people living in the home) Care Homes for Adults (18-65 years) Page 28 of 36 Evidence: has any input in the selection of staff that work at the home. This makes it difficult to plan effectively the kind of training and support that staff will need and the kind of duties that staff can safely and reasonably be allocated to perform. The acting manager has spent considerable time trying to improve administration and recording within the home and this has led to improvements in the way that peoples health, medication and personal care needs are met and documented. Staff have also worked hard to consolidate improvements in these areas. The people who live and work in the home are formally surveyed by Mentaur every year to gain their views about how the service is run. The report from the last survey conducted is not yet available. Staff confirmed that they have received statutory training in such areas as first aid and fire safety. Requirements made by the Environmental Health Officer following their visit in December last year have now been met. We saw evidence on site that the fire risk assessment was reviewed on 07/05/09 by external consultants who made a recommendation that polystyrene ceiling tiles be removed from office ceiling. The registered provider should advise the Commission when this work is scheduled and completed. Some older records relating to people living in the home (such as support plans and Medication Administration Records) are being stored in an unlocked cupboard on the second floor. All service users records should be stored securely at all times. Care Homes for Adults (18-65 years) Page 29 of 36 Are there any outstanding requirements from the last inspection? Yes  No  Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 30 of 36 Requirements and recommendations from this inspection Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No Standard Regulation Description Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set No Standard Regulation Description Timescale for action 1 1 5 The registered person must 31/07/2009 ensure that information in the service user guide is accurate and reflects the actual service provided in the home. This is so people have accurate information to help them decide if they wish to live at Herons Lodge. 2 24 16 The registered person must ensure that all bathrooms have suitable window coverings. 15/07/2009 This is to ensure the privacy and dignity of the people living in the home. 3 24 23 The registered person must 31/08/2009 ensure that the shower room on the second floor is made fit for use. Care Homes for Adults (18-65 years) Page 31 of 36 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set No Standard Regulation Description Timescale for action This is to ensure that people with a room on this floor have easy to toilet and washing facilities on the same floor. 4 24 23 The registered person must ensure that all the homes bath and shower rooms are equipped with safe heating. 31/08/2009 This is to ensure that people living in the home can bathe or shower without getting cold and without the risk of burning themselves on uncovered radiators or heated towel rails. 5 33 18 The registered person must ensure that staff are employed in sufficient numbers and with sufficient experience so that people living in the home can have all their needs effectively met. 31/08/2009 This is to ensure that there are sufficient staff on duty at all times, with the necessary experience to meet the needs of the people living in the home. 6 33 18 The registered person must ensure that there are sufficient staff on duty to ensure that the registered 31/07/2009 Care Homes for Adults (18-65 years) Page 32 of 36 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set No Standard Regulation Description Timescale for action manager does not have to routinely offer direct care and support to the people living in the home. This is to ensure that the acting manager has sufficient time to devote to the management and day to day running of the home and the supervision and support of staff. 7 35 18 The registered person must 30/09/2009 ensure that all staff have received appropriate training in working with people with learning disabilities and mental disorder This is to ensure that all staff have the training and skills necessary to meet the needs of the people for which the home is registered. 8 37 41 The registered person must 31/07/2009 ensure that all records relating to people living in the home (including those that have been archived) are stored securely This is to ensure that the confidentiality of people living in the home is not compromised. Care Homes for Adults (18-65 years) Page 33 of 36 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 1 Consideration should be given to producing the service users guide in alternative formats to ensure that it can be understood by all the people living in the home. It is unclear how the one to one staff time for one person is being used on Saturdays. This should be clearly recorded to ensure that the person is receiving the commissioned service. For those people living in the home who do not have well developed, formal methods of communication it should be clearly noted within their support plans, how they express their unhappiness or displeasure and how staff should respond to this. Given the complexity of need of the people living in the home and the behavioural challenges that they sometimes exhibit, the registered persons should ensure that extended working hours do not compromise the quality of care that people receive. Verifiable evidence that staffs names have been checked against the vulnerable adults register must be available for inspection. It is strongly recommended that the acting manager be involved in the selection and interviewing of the staff who work in the home she manages. The registered person should ensure that certificates received by staff members following training are given to the staff member concerned rather than being kept at the parent organisations head office. Copies of these certificates should also be kept on the staff file held at the home so that they are available for inspection to verify training. The registered provider must ensure that staff receive appropriate supervision as detailed within their contracts of employment and that this supervision is appropriately documented 2 6 3 22 4 33 5 34 6 34 7 35 8 36 9 42 We saw evidence on site that the fire risk assessment was Care Homes for Adults (18-65 years) Page 34 of 36 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations reviewed on 07/05/09 by external fire safety consultants have recommended that polystyrene ceiling tiles be removed from the office ceiling. The registered provider should advise the Commission when the work recommended is scheduled and completed. Care Homes for Adults (18-65 years) Page 35 of 36 Helpline: Telephone: 03000 616161 or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Care Homes for Adults (18-65 years) Page 36 of 36 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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