Inspection on 07/06/06 for Herons Lodge

This inspection was carried out on 7th June 2006.

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

The inspector 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 07/07/08

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 09/07/2008.

CARE HOME ADULTS 18-65 Herons Lodge 138 Northampton Road Market Harborough Leicestershire LE16 9HF Lead Inspector Martin Hefferman Unannounced Inspection 7th June 2006 09:50 Herons Lodge DS0000035094.V298126.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.V298126.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.V298126.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 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) www.mentauruk.com Mentaur Limited Vacant 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.V298126.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No one falling within category MD may be admitted to the home unless that person also falls within category LD, i.e. dual disability. 10th January 2006 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 £615 to £1933. Information for prospective residents was available. The acting manager agreed to update a guide for residents to reflect changes to the management of the home. Herons Lodge DS0000035094.V298126.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A visit to the home took place on 7th June 2006, lasting approximately six and a quarter hours. The main method of inspection used on that day was ‘case tracking’ which involved selecting two residents and tracking the care they receive through review of their records, discussion with them (where appropriate), the care staff and observation of care practices. A number of the residents have limited verbal communication. Two residents were spoken to during the course of the visit. The inspection also took account of all information received since the date of the last visit, including the owner’s selfassessment. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Herons Lodge DS0000035094.V298126.R01.S.doc Version 5.2 Page 6 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.V298126.R01.S.doc Version 5.2 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Assessment procedures appear to be effective, ensuring that the needs of any prospective residents should be identified. EVIDENCE: The outcome for standard 2 could not be fully assessed on this occasion. There have been no admissions since July 2005. Both of the residents who were chosen for the purposes of case tracking moved to the home in 2003. The last inspection looked at the home’s assessment procedures. It found that the home had reviewed its procedures to ensure that the needs of any prospective residents would be identified. Herons Lodge DS0000035094.V298126.R01.S.doc Version 5.2 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff members have access to the information they need to meet residents’ needs. EVIDENCE: Individual plans were available for the residents who were chosen for the purposes of case tracking. The plans that were inspected had been reviewed recently. Staff members had signed to confirm that they have read them. The acting manager stated that residents’ files have been reorganised since the date of the last inspection to ensure that care plans do not get ‘lost’ with other information. Risk assessments were available for the residents whose records were inspected. One of the plans that were inspected set out the cultural needs & dietary requirements associated with a resident’s ethnicity. A resident and a member of staff were in the process of completing a person-centred plan on the day of the inspection. The acting manager stated that staff members were undertaking training to enable them to develop person-centred plans with all residents. Herons Lodge DS0000035094.V298126.R01.S.doc Version 5.2 Page 9 One resident stated that he could decide how to spend his day, choosing for example when to get up and go to bed. It was evident that residents are able to make full use of communal areas and their bedrooms. A weekly meeting is held at which residents have an opportunity to suggest activities and decide on menus. Herons Lodge DS0000035094.V298126.R01.S.doc Version 5.2 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 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. Arrangements relating to the various aspects of residents’ lifestyles appear to be well managed. EVIDENCE: The majority of residents attend a day service run by the registered provider in Northampton. One resident stated that he undertakes activities on a one-toone basis for which additional funding has been agreed. Similar arrangements have been agreed for two other residents. The acting manager stated that staff members were in the process of developing individual activity plans for all residents. A number of residents were getting ready to go to a disco on the day of the inspection; they had gone swimming at a local leisure centre the day before. Photographs suggested that the residents had enjoyed a holiday at Butlins during May 2006. Residents indicated that they are in regular contact with their families and friends. One of the residents is due to go on holiday with a friend from another home run by the registered provider later in the year. Herons Lodge DS0000035094.V298126.R01.S.doc Version 5.2 Page 11 Residents appeared to enjoy the meal that was provided on the day of the inspection although one person indicated that it had upset her later on. The acting manager stated that this would be taken into account when deciding whether to offer her the same meal in the future. Residents are involved in determining the menus at a weekly meeting. Herons Lodge DS0000035094.V298126.R01.S.doc Version 5.2 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements for managing residents’ personal & healthcare needs appear to be well managed. EVIDENCE: One resident stated that he was happy with the support he receives from staff members. The individual plans that were inspected detailed the personal care each person requires. The plans also set out details of any healthcare needs that have been identified and of any action that is felt to be necessary as a result. A record is kept of any healthcare appointments attended by residents. An audit is completed of all incidents that occur to enable staff to identify any patterns. None of the residents who were chosen for the purposes of case tracking were able to manage their medication. Records of the medicines administered to residents met relevant requirements. The acting manager undertakes regular audits on stocks of medication, the use of ‘as required’ medicines and on the completion of records ensuring that a good standard is maintained. A contract pharmacy inspected medication arrangements at the home during March 2006. Records indicated that no issues were identified. Staff members receive training and are assessed as competent before they are able to administer medication. Herons Lodge DS0000035094.V298126.R01.S.doc Version 5.2 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has effective complaints & adult protection procedures, which should ensure that residents’ views are acted upon and that they are protected from abuse. EVIDENCE: One resident stated that he would speak to staff if he had any concerns. It was not possible to ascertain whether other residents were aware of the home’s complaints procedure. The acting manager stated that one complaint had been received since the date of the last inspection. This related to an issue between two members of staff. The home has policies and procedures on the protection of vulnerable adults and whistle blowing. Staff members have received training on the action to be taken in the event of an allegation or suspicion of abuse. Herons Lodge DS0000035094.V298126.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a comfortable and safe environment. EVIDENCE: Residents indicated that they were happy with their environment. They are encouraged to personalise their rooms and to have their belongings around them. The areas of the home that were inspected were decorated and furnished to a satisfactory standard. They were generally clean and odour free. An issue with one of the rooms that were inspected was brought to the attention of the acting manager. A record is kept of any issues that require attention. At the time of the inspection, the home was in the process of developing an area of the garden. Herons Lodge DS0000035094.V298126.R01.S.doc Version 5.2 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing arrangements are generally well managed. EVIDENCE: One resident stated that he got on well with staff members. Other residents appeared to enjoy a positive relationship with the staff on duty at the time of the visit. Records indicate that there is a stable staff group and that the use of agency staff is largely limited to one-to-one support. The records relating to two members of staff were inspected. Whilst one of them indicated that appropriate pre-employment checks had been carried out, the second suggested that the home had yet to receive a Criminal Records Bureau disclosure. This issue was brought to the attention of the acting manager. New members of staff complete induction training to the standards set by Skills for Care (the Training Organisation for Personal Social Services). Records indicate that six members of care staff have completed National Vocational Qualification level 2 and one NVQ level 3. In addition, one of the team leaders is a qualified social worker. Five of the seventeen members of care staff have started NVQ level 2 and three level 3. Records indicate that staff members have received training on issues relevant to their work. Herons Lodge DS0000035094.V298126.R01.S.doc Version 5.2 Page 16 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home appears to be generally well managed. EVIDENCE: The home is currently managed by Mentaur’s Service Development Manager. She stated that the process of recruiting a permanent manager is ongoing, with further interviews being held on the day of the inspection. The Responsible Individual (a representative of the company) completes Regulation 26 reports (visits by the registered provider). The acting manager stated that the company had completed a survey of the views of residents and staff. She agreed to forward the results. Staff members have received training on a number of safe working practices. Records indicate that fire tests & drills generally take place at the required frequency although the fire alarm system did not appear to have been tested since 19th May 2006. This issue was brought to the attention of the acting Herons Lodge DS0000035094.V298126.R01.S.doc Version 5.2 Page 17 manager. The home was in the process of updating its general risk assessments at the time of the inspection. Herons Lodge DS0000035094.V298126.R01.S.doc Version 5.2 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 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 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 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.V298126.R01.S.doc Version 5.2 Page 19 Are there any outstanding requirements from the last inspection? No 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. Refer to Standard Good Practice Recommendations Herons Lodge DS0000035094.V298126.R01.S.doc Version 5.2 Page 20 Commission for Social Care Inspection Northamptonshire Area Office 1st Floor Newland House Campbell Square Northampton NN1 3EB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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