Inspection on 07/07/08 for Herons Lodge

This inspection was carried out on 7th July 2008.

CSCI found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Herons Lodge 11/08/09

Herons Lodge 27/05/09

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 28/09/2008.

CARE HOME ADULTS 18-65 Herons Lodge 138 Northampton Road Market Harborough Leicestershire LE16 9HF Lead Inspector Stephanie Vaughan Unannounced Inspection 7th July 2008 09:00 Herons Lodge DS0000035094.V367999.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Herons Lodge DS0000035094.V367999.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Herons Lodge DS0000035094.V367999.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Herons Lodge Address 138 Northampton Road Market Harborough Leicestershire LE16 9HF 01858 465441 01858 465441 lucikad@yahoo.co.uk www.mentauruk.com Mentaur Limited 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) Ms Lucie Kaderabkova Care Home 10 Category(ies) of Learning disability (10), Mental disorder, registration, with number excluding learning disability or dementia (10) of places Herons Lodge DS0000035094.V367999.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 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. The maximum number of service users who can be accommodated is 10. 7th June 2006 2. Date of last inspection Brief Description of the Service: Herons Lodge is a care home providing personal care and accommodation for up to ten adults with learning disabilities. The premises are owned by Mentaur Limited, who run a number of care homes in the Midlands. The home is located close to the town centre of Market Harborough where residents have access to shops, pubs, the post office and other amenities. The home is easily accessible by private or public transport. The range of facilities includes two lounge areas and a dining room for communal use. The home is a converted property with bedrooms on two floors. Access to the first and second floors 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 residents. At the time of the inspection, fees ranged from £602.74 to £1,990.89 per week with additional charges for hairdressing, podiatry, clothing, toiletries and other personal items at variable cost. The service provides information on request; copies of the Commission for Social Care Inspection reports are available in the home. Herons Lodge DS0000035094.V367999.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. Prior to this statutory inspection, a period of five hours was spent in preparation. This comprised reviewing the Annual Quality Assurance Assessment, as document sent to us by the provider, the previous inspection reports and associated requirements, the service history and other documentation. A total of 8 Comment cards were sent to people who use the service and 10 comment cards were sent to staff. The management confirm that these have been sent to the Commission, however these have not yet been received. The Commission have received one compliant about the washing machine not working and the impact that this was having on one resident in particular. However this has been investigated by the provider and there was no evidence to support this concern and alternative arrangements had been made until the washing machine had been repaired, this is now in good working order. There have been four Safeguarding Adults allegations about this service; these have been subject to independent investigation under the Local Authority Guidelines for the Safeguarding of Adults. In three of these allegations there was no evidence to support the allegations and for one the outcome is as yet unknown. The Commission have a focus on Equality and Diversity and issues relating to this are also included in the main body of the report. This site visit to the home was conducted over a period of eight and a half hours during which the inspectors made observations and spoke to residents and staff. A limited tour of the premises was conducted which involved viewing the communal areas and a selection of the private accommodation. Case tracking is the method used during inspection where of a sample of four residents were selected and all aspects of their care and experiences reviewed, including individual plans of care and associated documentation. The service specialised in the care of people who have learning disability and who have limited communication abilities and as such were unable to recollect or to fully express their views about this service. In these circumstances observations are used to inform the inspection activity. The Registered Manager was present during this inspection. Herons Lodge DS0000035094.V367999.R01.S.doc Version 5.2 Page 6 What the service does well: The service makes sure that they have the right information so that they can care for the people who use the service properly and admissions are managed well. People who use the service have a key worker who supports them in all aspects of their life at Herron’s Lodge. Care plans show how people who use the service are supported to make choices in their daily lives and that they are supported to take risks. Routines are flexible and the staff know the things that the residents like to do and how they like to do them. People who use the service can be involved in household activities, like laundry, cooking and cleaning. They are also able to join in-group or individual activities based on their interests. People who use the service are supported to go out into the community to use local facilities such a clubs, discos and restaurants. The staff use varied ways to communicate with people who use the service, this can be with sign language, visual aids and interpretation of facial expressions, body language and vocalisation. People who use the service are able to visit their families and are also able to receive their chosen visitors at Herron’s Lodge. Staff support them to maintain relationships with family, friends and relationships with their chosen partner. People who use the service are involved in making decisions in the home such as menu planning and the organisation of activities. The meals are varied and balanced to provide choice and a healthy diet. Residents said that they liked the food and this is well presented and served in good portion sizes, foods appropriate to the culture of the individuals are also available. People who use the service have the right support to make sure that they are able to care for themselves properly and are supported in the way that they like. This means that they are able to express their personality, age and culture in the way that they present themselves. Herons Lodge DS0000035094.V367999.R01.S.doc Version 5.2 Page 7 Individual plans of care show that people who use the service are supported to look after their health by seeing the right doctors and specialists when it is needed. Residents were able to indicate that they felt they were supported well by the staff. People who use the service are checked to see if they are able to handle their own medication and their consent is obtained if they need the staff to do this for them. Medication is managed well at Herron’s Lodge, people who use the service have their medication as it is prescribed and the way that it is managed is safe. People who use the service were able to indicate that they felt safe living at Herron’s Lodge and that the staff were nice to them. Staff know how to protect people form abuse and staff have the right training to make sure that the home is a safe place to live. People who use the service have their own bedrooms and are able to have their own belongings with them. Staffing levels have recently been reviewed and increased to accommodate the needs of the people who use the service and staff have the right checks before they start working in the home. The management make sure that the right checks are done so that the home is a safe place to live. People who use the service are supported to manage their money and staff make sure that this is done properly. What has improved since the last inspection? The service is updating all the care plans to make sure that they are ‘person centred’ which means that they show how individual needs and wishes to be cared for. A new manager has been appointed and she is now registered with the Commission for Social Care Inspection. Herons Lodge DS0000035094.V367999.R01.S.doc Version 5.2 Page 8 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 Herons Lodge DS0000035094.V367999.R01.S.doc Version 5.2 Page 9 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Herons Lodge DS0000035094.V367999.R01.S.doc Version 5.2 Page 10 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 Herons Lodge DS0000035094.V367999.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, & 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Admission processes are robust and ensure that the service is able to meet the needs of people who move into the home. EVIDENCE: The service has a Service Users Guide is displayed in the home, the purpose of this document is to tell people who use the service what it is like to live in the home. At present it is written in a formal style and although it is illustrated with pictures, it is not suitable for all of the people who live there. Consideration should be given to developing this document in other formats so that people with learning and visual disability and those whose first language is not English are able to use it. It also needs to be checked to make sure that it contains all of the information as set out in the National Minimum Standards. The service keeps a copy of the Commission for Social Care Inspection Reports in the office and these are available to people who use the service, the staff and people who may wish to use the service in the future. Herons Lodge DS0000035094.V367999.R01.S.doc Version 5.2 Page 12 No new people have moved into the home since the last inspection, the service has 2 vacancies, however one of the rooms is currently being used by the staff who do ‘sleep in’ shifts. At the moment there are seven females and one male living at the home, the management know that it would be better if the next person to move into the home was male so that the existing male could have the company of another male resident. Through discussion with staff it was established that the management make sure that new admissions to the home are managed well and include opportunities to visit the home on a number of occasions so that new people can get to know what it might be like to live there, get to know the other residents and the staff. The service conducts their own preadmission assessment as well as obtaining assessments form the funding authorities. This means that the service makes sure that it can offer the right care to new people. The existing residents are also consulted about their views as to whether they feel that they would be able to get along with the new person. The management also make sure that there are staff allocated to support the new person 24hrs a day to help them to settle in. Individual plans of care evidenced that residents have appropriate contracts in place, which set out what the home is to provide, and the costs involved. Herons Lodge DS0000035094.V367999.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service have control over their lives and are enabled to enjoy a lifestyle that promotes choice and independence. EVIDENCE: Each person who lives at Herron’s Lodge has an individual plan of care, this is a file, which contains information to staff about how the person needs and wishes to be cared for. These are being developed to make sure that they are ‘person centred’ and are in a style, which is easier for people to understand and enable them to be involved with the planning and the review. The plans are based on the admission assessments and set out in detail all of the person’s personal, health and social care needs. These show that people Herons Lodge DS0000035094.V367999.R01.S.doc Version 5.2 Page 14 who use the service have a key worker who works with them regularly to make sure that they are being supported in the right way. The plans contain detailed instruction to staff about how people are to be supported in the management of challenging behaviour and any restrictions on them are seen to be in the best interests of the individual and to be supported by the right risk assessments. Residents preferences are documented in the individual plans of care, this means that staff are able to support residents in making decisions about their lifestyles, this includes decisions about preferred routines, meals and meal times and are able to choose whether or not to participate in organised activities. Residents are able to move freely around the home and to choose how to spend their time including participation in household activities, which also promote their independence. Residents were able to confirm that they were able to make choices in their daily lives and that they enjoyed participating in these tasks. The daily records are detailed and show how residents are cared for and supported to make choices on a daily basis. The staff make sure that the individual plans of care are up to date and are revised to accommodate the changing needs of the residents. Residents are supported to take risks within their daily lives one example is where a resident has chosen to spend time with horses and be involved in their care. These activities are supported by appropriate risk assessments. There are also risk assessments in pace for the residents participation in household activates and general health and safety within the home. There has been one incident where are resident had sustained a serious injury following a fall down the stairs however the individual risk assessments need to be further developed to specifically address the risks involved. Individualised risk assessments also need to be further developed to ensure that they demonstrate how the risks are to be reduced or managed when residents access the local community and interact with members of the public. Individual plans of care evidenced that residents also have access to advocacy services and the management are aware of the local Independent Mental Capacity Advocate Services. Herons Lodge DS0000035094.V367999.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Social activity and meals are both managed well are creative and provide daily variation and interest for people living in the home. EVIDENCE: People who use the service are supported to attend local day centres and to use the local community for walks leisure and social activities such as local discos, clubs and restaurants. Arrangements are also in place to support people to maintain their faith should they wish to do so. Staff use a variety of techniques to communicate with residents including Makaton, visual aids and observation of facial expression and body language. Herons Lodge DS0000035094.V367999.R01.S.doc Version 5.2 Page 16 People are encouraged to maintain relationships with their families by visiting their homes and receiving them at their home. They are also supported to maintain contact by the sending of greeting cards to celebrate special occasions. Residents are also supported to develop and maintain special relationships with their chosen partner. Daily routines are flexible; resident’s preferences are recorded in the individual plans of care and are well known to staff. Mealtimes are flexible within the constraints of the residents planned activities. Bedrooms doors are fitted with appropriate privacy locks and are supported to hold keys to their bedroom doors. Staff are mindful of the residents privacy and knock on residents bedroom doors and await permission before entering. Staff were seen to relate well to residents and to address them by their preferred name. The service has regular weekly residents meetings where decisions are made about the menus. Staff support residents to balance their individual preferences whilst maintaining a varied and balanced diet. Menus reflected individual and cultural preferences, including appropriate alternatives on the day if the planned meal is not wanted. Residents who attend the day centre are provided with a packed lunch comprising sandwiches and fruit. Lunchtime service was viewed, the food was prepared from fresh produce and served in the lounge diner, the atmosphere was relaxed and residents were supported with discreet assistance was provided. Residents were able to indicate satisfaction with the food provided by the home. Herons Lodge DS0000035094.V367999.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have a detailed plan of care, which indicates that they are treated as individuals and that their health care needs are addressed. EVIDENCE: Through observation it was established that the staff provide sensitive personal care to residents, which is well documented within the individual plans of care. Care plans also demonstrate that individual needs and preferences are taken into account, residents are able to express their gender in their personal appearance and are dressed appropriately for their age. Residents from different ethnic backgrounds have access to appropriate toiletries and are able ethnic origins in their personal care and appearance. Residents are also able to participate in regular organised health and beauty sessions. Herons Lodge DS0000035094.V367999.R01.S.doc Version 5.2 Page 18 Most of the residents are female and this is reflected in the staff group, however there are also adequate numbers of male carers who are able to support and relate to the only male resident. Residents are able to express preferences about the staff members that they wish be supported by. Routines are flexible and times of rising and retiring to be are recorded, staff are able to interpret the individuals wishes though observation of their body language facial expression and other means of communication. Individual plans of care evidenced that residents have access to appropriate hospital and health care service such as Consultant Psychiatrists, General Practitioners, Community Learning Disability Teams, Speech and Language Therapists, Dieticians, Podiatrists and Opticians. There is also evidence that residents have access to routine health checks and health promotion activities. The service monitors the well being of residents in the regular assessment of blood pressure, weight and general observation. Residents appeared to be healthy and well cared for; they were able to confirm that they were well cared for by the staff. There is evidence that people who use the service are assessed for their ability to self medicate and their formal written consent is obtained for the staff to administer medication on their behalf. Medication systems were seen to be managed well, the service uses a monitored dose system which provides accurate records of the medicines received by the home Medication Administration Records indicated that medication is given as prescribed and these records are well maintained. The administration of medication was observed and demonstrated that the staff practice is safe; there have been no medication errors in the home. The service returns all unused medication to the local pharmacist on a monthly basis and maintains accurate records. There are adequate arrangements in place for the storage of medication however this needs to be reviewed to ensure compliance with the new RBPS (Royal British Pharmaceutical Society) guidelines. One new tube of cream was not dated at the time of opening, however this was immediately identified by the Registered Manager who took appropriate action to address this. The Registered Manager conducts regular and spot check of the medication systems ad there was evidence that staff have training in the Safe Administration of Medication. Herons Lodge DS0000035094.V367999.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a complaints robust procedure; good staff awareness and attitudes regarding the Safeguarding of Adults so that residents felt safe and are protected. EVIDENCE: The service has a complaints policy, which is available in the Service Users Guide and throughout the home in user friendly formats. In general it contains appropriate information about the times scales in which a complainant can expect to receive an acknowledgement and a response. However the current policy does not contain the contact details of the provider or the commissioning authorities. Information regarding the Commission for Social Care Inspection contact details is currently out of date. The complaints file was viewed and seen to evidence compliance with the service policy on complaints. There has been one complaint since the last inspection and there was evidence that this had been investigated and no evidence had been found to support the concerns raised. One resident was able to confirm that they knew what to do if they were unhappy about something. Staff spoken to were able to confirm that they were aware of their responsibilities in receiving complaints and also the whistle blowing policy. Herons Lodge DS0000035094.V367999.R01.S.doc Version 5.2 Page 20 They were also knowledgeable about the how to interpret the non-verbal communication expressed by residents who were unable to vocalize their opinions. Residents appeared to be calm, well presented and well cared for they were also able to indicate that they felt safe living at Herron’s Lodge. However there have been a significant number of incidents of physical aggression between residents since the last inspection. There is evidence that residents requiring one to one support are supervised during their waking hours. In addition arrangements have been made to ensure that the security of residents is maintained throughout the night. The number of incidents between residents appears to have reduced during recent months due to the actions taken by the management. There was evidence that staff are trained in the management of challenging behaviour and that the use of restraint is minimised. There have been four Safeguarding Adults Alerts made about this service since the last inspection these have been referred to the Local Authority Adult Social Care Service. Three of these have been investigated and no evidence has been found to support the allegations. The outcome of one is as yet unknown. Staff are clear about their responsibilities in the Safeguarding of Adults and have received in house training. The Registered Manager has liaised with the Local Authority for guidance regarding the referrals of Safeguarding Adults allegations. The service has access to the revised Local Authority Guidelines on the Safeguarding of Adults however the fact that all of the residents residing in Herron’s Lodge are funded by other authorities has the potential to cause confusion about the referral process. Inspectors are satisfied that the Registered Manager has followed the guidance that was provided by representatives of the Local Authority. Herons Lodge DS0000035094.V367999.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The standard of the environment meets the basic needs of the existing residents however the experience of both the existing and prospective residents could be enhanced by further improvements in the environment to meet the specific needs of individuals. EVIDENCE: The premises comprise a period residential property that has been extended and is registered to provide care for ten residents. There is a large lounge diner in which most people spend their time. In addition there is a quiet room where residents are able to take time out or receive their visitors. Each resident has their own bedroom, which contains appropriate fixtures and fittings, including privacy locks and washbasins. Windows were fitted with Herons Lodge DS0000035094.V367999.R01.S.doc Version 5.2 Page 22 safety restrictors, however radiators are exposed and although there is a general risk assessment in place for the environment, individualised risk assessments need to be conducted for individuals who have a history of falls or who are unable to alert staff in the event of an emergency such as an epileptic fit. Residents were happy to show inspectors their rooms and these showed that people are able to bring in their own personal possessions and have access to electrical items such as televisions and CD players. Some of the residents have non-slip wood effect flooring however the carpets in one of the residents bedrooms, the hall, stairs and landing were particularly stained. This was discussed with the Registered Manager who has confirmed that arrangements to clean the carpets within the next week have now been made. The standard of the environment is adequate for the needs of the existing residents however guidance should be sought from organisations on how to improve the environment for residents who have limited visual capacity. In addition the premises do not provide access for wheel chair users, the corridors particularly upstairs are narrow and have an additional small flight of stairs. There is some evidence that adaptations have been made for example in ther provision of an additional stair rail to promote safety of residents when using the stairs. Residents have access to shower facilities, however these are basic and are now in need of refurbishment to ensure that they are able to continue to meet the needs of the residents as they become older and that they are pleasant to use. There are adequate supplies of hot water; staff were able to confirm that the equipment was in good working order. In general the environment was safe, clean and hygienic. The main entrance is currently through the extension at the back of the building through the car park, whereas there is a more pleasant access to the old front door, which is rarely used through the front garden. The Registered Manager has agreed to consider the possibility of reverting to the use of the front door. The rear garden is private, enclosed and well maintained which provides residents with a pleasant area in which to spend their time when the weather is fine. Herons Lodge DS0000035094.V367999.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service employs appropriate numbers of inducted and trained staff to ensure that the residents needs are met. EVIDENCE: The service has a staff duty rota that identifies which staff are on duty for each shift. This demonstrates that in general there are four staff on duty throughout the day with one waking and one sleeping staff at night. This means that there are in general adequate staffing levels in the home to enable residents to receive their one to one support and be able to participate in activities and attend day centres. However staff confirmed that there have been some staff shortages over recent months as two carers have unexpected left employment and another is on maternity leave. The Registered Manager confirmed that two new staff have been recruited and are currently awaiting appropriate recruitment checks before commencing employment. She has also confirmed that the staffing hours have been increased from 486 hours per week to 514 hours per week to meet the needs of the existing residents. Through Herons Lodge DS0000035094.V367999.R01.S.doc Version 5.2 Page 24 discussion with the Registered Manager it was established that in general she is included within the staffing levels and it was evident that she spends a considerable amount of time with the residents or in practical tasks within the home. This means that in the event of unexpected staff absence or in an emergency that the service is limited in the immediate response that they are able to make. Staff files demonstrate that robust recruitment processes are in place, two references are obtained, including one from the most recent employer and appropriate clearances are obtained. All Criminal Records Bureau Clearances showed that a povafirst check had been requested although the dates that these were received are not currently held on file within the home. Staff spoken to were able to confirm that they had had Criminal Records Bureau Clearances and that new staff have povafirst checks before they commence employment. The Commission have received confirmation that dates that the povafirst checks have been received will be included within all staff files within the week. The existing staff team are all white European, however the management are mindful of the need to ensure that wherever possible the staff group reflect the ethnicity and culture of the existing residents. The gender of the current staff team reflects the mix of the existing residents. In addition the service also employs a domestic assistant who has some learning disability herself, residents enjoy spending time with her and are able to help with basic house hold tasks. Residents were ale to confirm that staff were nice to them and that they felt safe living at Herron’s Lodge. Staff files show that staff have the right training and that this is repeated within a timely way. Staff have access to National Vocational Qualification in Care level 2 training and are encouraged to take further training in their National Vocational Qualification in Care level 3 Other mandatory training includes Induction, Fire Safety, Basic Food Hygiene, Health and Safety, First Aid, Infection Control, Safeguarding Adults. There is also training appropriate to the needs of the individual residents such as Epilepsy, Learning Disability, Mental Health, and Challenging Behaviour and training in de-escalation techniques and restraint (NAPPI). Most of the training appears to be in house and staff would benefit from access to external accredited training, particularly in the Safeguarding of Adults, this is available from the local authority free of charge and is also available in more advanced sessions for senior staff who have responsibility for the referral process. Staff files also showed that staff supervision is conducted on a regular basis. Herons Lodge DS0000035094.V367999.R01.S.doc Version 5.2 Page 25 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Appropriate leadership, guidance and direction means that the service is managed in the best interests of the people who use it. EVIDENCE: Following the last inspection a new acting manager has been appointed and she was successful in her application to become registered with the Commission in June 2007 and has commenced working towards her Registered Managers Qualification. Staff were able to confirm that the Registered Manager was approachable and that the service was run in the best interests of the people who use it. The providers are currently making arrangements to Herons Lodge DS0000035094.V367999.R01.S.doc Version 5.2 Page 26 provide internet access to the service to enable management and staff to access information such as the Commission for Social Care Inspection Professional website, National Institute for Health and Clinical Excellence and the Health and Safety Executive website. Quality assurance systems are in place and comprise regular audits of care plans, medication systems, and the environment including room and water temperatures. There was also evidence that the service seeks the views of the people who use it and that these views are used to inform service development. The service holds small amount of money for some of the residents; this is stored appropriately in a secure facility and within individual containers. Appropriate records of money received, expenditure and the remaining balance are maintained; receipts are also retained to evidence expenditure. The Registered Manager conducts audits of these systems at least once a day. The Service maintains appropriate fire records and these evidence that the right checks are being done, this includes checking fire alarms, emergency lighting and other fire fighting equipment, fire drills are also conducted on a regular basis. Accident records were checked and these showed that accidents where staff are involved are recorded. On further enquiry it was established that separate records are maintained for accidents and incidents involving residents. These meet the requirements of the National Minimum Standards, however it is not clear whether these meet the requirements of other regulatory bodies such as the Health and Safety Executive. The certificate of Registration is up to date and was displayed in the main entrance, the insurance certificate is also displayed there, and this appeared to be out of date. However a new certificate has been obtained and is currently displayed in the office. There are general environmental risk assessments for the in place, however individual risk assessments need to be further developed for risks such as falls and exposed radiators. Herons Lodge DS0000035094.V367999.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Herons Lodge DS0000035094.V367999.R01.S.doc Version 5.2 Page 28 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. Standard Regulation Requirement Timescale for action 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. Refer to Standard OP1 OP1 OP9 OP13 OP20 OP22 OP23 Good Practice Recommendations The Service Users Guide should be reviewed to ensure that it complies with the criteria set out in standard 1 of the National Minimum Standards. The format of the Service Users Guide should be reviewed to ensure that the information is accessible to people who use the service in appropriate formats Individual risk assessments should be further developed to ensure that the risks associated with any activities in which the residents participate are reduced and managed. Individualised risk assessments should be developed to show how resident’s behaviours are to be managed when they access the community. The storage of medication should be reviewed to ensure that it complies with new guidance issued by the RBPS. The complaints procedure needs to be reviewed to ensure that it contains al th right contact information. Management and staff should have access to external training pertaining to the relevant Local Authority DS0000035094.V367999.R01.S.doc Version 5.2 Page 29 Herons Lodge 8. 9. OP24 OP24 Guidelines on the Safeguarding of Adults Individualised risk assessments should be conducted for the risks associated with exposed radiators. The standard of the environment needs to be reviewed to make sure that it meets the continuing and changing needs of the people who use the service. Staff training should be reviewed to ensure that staff have access to external accredited training relating to the mandatory subjects. The Registered Manager should not be included in the care staffing hours so that the service has the flexibility to cover unexpected staff absence and to respond to emergency situations in the home. The way that the service records accidents and incidents involving people who use the service should be checked with other regulatory bodies to make sure that it complies with their requirements. 10. OP35 11. OP37 12. OP38 Herons Lodge DS0000035094.V367999.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection East Midland Regional Office Unit 7 Interchange 25 Business Park Bostocks Lane Nottingham NG10 5QG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000035094.V367999.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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