CARE HOME ADULTS 18-65
Ivor Lodge Limited 452-454 Hinckley Road Leicester Leicestershire LE3 0WA Lead Inspector
Kim Cowley Unannounced Inspection 23rd September 2005 1:00 Ivor Lodge Limited DS0000043227.V252781.R01.S.doc Version 5.0 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 Ivor Lodge Limited DS0000043227.V252781.R01.S.doc Version 5.0 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. Ivor Lodge Limited DS0000043227.V252781.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Ivor Lodge Limited Address 452-454 Hinckley Road Leicester Leicestershire LE3 0WA 0116 2547141 0116 2547141 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) Ivor Lodge Limited Mrs Sobha Chooramun Care Home 14 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (14) of places Ivor Lodge Limited DS0000043227.V252781.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. No additional conditions of registration. Date of last inspection 9th June 2005 Brief Description of the Service: Ivor Lodge is a residential care home for people with mental health needs. It is situated in a large detached house on the Hinckley Road, close to a range of local amenities. The home has ten single and two double bedrooms. There are two lounges, a conservatory where smoking is allowed, and a dining room. To the rear of the house is a small garden with a patio area. Ivor Lodge Limited DS0000043227.V252781.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on a weekday. When undertaking inspections the Commission for Social Care Inspection (CSCI) focuses on the outcomes for residents living in a home. In order to do this, the inspector ‘case tracked’ three residents. This means the inspector checked their care records and met with them. In addition the inspector met a further two residents, and interviewed the Owner/Manager and one of the carers. Further care and other records were examined. The quality of the Owner/Manager’s work and the involvement of residents in the running of the home are commended. Two Recommendations were made regarding the home’s complaints procedure and vulnerable adults policy. What the service does well:
Ivor Lodge is a well-run friendly and relaxed home with an established team of professional carers. Some of the residents have been at the home for many years and all those interviewed were satisfied with the care they receive. The following comments were made, ‘I’m very happy living here’, ‘I’m settled here’, ‘Being here is my mainstay’, ‘Nothing can be improved on in this home’, and ‘I never want to leave this place.’ Records showed that staff work closely with other health and social care professionals. Staff know the residents well and are quick to respond to their needs. One resident said, ‘My tooth hurt so Sadna (the Owner/Manager) stopped what she was doing and rang the dentist and got me an appointment straight away.’ Another resident commented ‘A while back I felt down and the staff noticed. Within one day it was all sorted out. They called my CPN and she changed my medication.’ The Owner/Manager has run care homes for 14 years and is a qualified mental health nurse. She works in the home full-time and is committed to delivering quality care. All residents interviewed priased the Owner/Mananger and their comments included, ‘I have never seen Sadna lose her temper or get ruffled’, ‘Sadna holds everything together. She is always there for us’, and ‘Sadna employs some really good staff.’ The Owner/Manager is commended for her work. Residents influence the running of the home. Meetings are held every Monday so they can decide the menus and activity programmes for the week. They are also involved in major decisions about the home. The conservatory was turned into a smoking room at their request. This involvement of residents in the running of the home is commended. Ivor Lodge Limited DS0000043227.V252781.R01.S.doc Version 5.0 Page 6 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. Ivor Lodge Limited DS0000043227.V252781.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ivor Lodge Limited DS0000043227.V252781.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These Standards were inspected at the home’s previous inspection on 9 June 2005. Ivor Lodge Limited DS0000043227.V252781.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 9 Care plans are being updated and are clear and informative. Staff support residents in taking responsible risks. EVIDENCE: Staff know the residents well and are quick to respond to their needs. One resident commented ‘A while back I felt down and the staff noticed. Within one day it was all sorted out. They called my CPN and she changed my medication.’ The Owner/Manager said residents are risk assessed by health and social services staff prior to admission. Risk assessments are then reviewed and updated by staff at the home in conjunction with CPNs. A number of residents smoke and they are able to use the heated conservatory or the garden for this, but smoking is not allowed in any other part of the home due to the risk it presents.
Ivor Lodge Limited DS0000043227.V252781.R01.S.doc Version 5.0 Page 10 Residents who go out unaccompanied are informed of risks and given support and advice. Staff teach them road safety and show them where nearby pedestrian crossings are. Residents take the telephone number of the home with them when they go out. Ivor Lodge Limited DS0000043227.V252781.R01.S.doc Version 5.0 Page 11 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These Standards were inspected at the home’s previous inspection on 9 June 2005. Ivor Lodge Limited DS0000043227.V252781.R01.S.doc Version 5.0 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 Residents choose how much assistance with personal care they would like. A range of health care professionals provides services to the home. Medication is securely kept and properly administered. EVIDENCE: The Owner/Manager said that at present all residents are mostly self-caring, although some need prompting or minimal assistance. Staff talk to residents about what help they need and this is recorded in their care plans. Residents can bath/shower as often as they like, for example one resident likes to have two showers a day while another has one bath a week. All residents are registered with local GPs and have consultant psychiatrists, some also have CPNs and/or care managers. Local dentists and opticians either visit the home or see residents in the community. One resident said, ‘My tooth hurt so Sadna stopped what she was doing and rang the dentist and got me an appointment straight away.’ Medication is kept securely and properly administered with records kept. The home’s contract pharmacist last inspected on 25.06.05 and was satisfied with the home’s medication systems. Staff are trained in house in medication
Ivor Lodge Limited DS0000043227.V252781.R01.S.doc Version 5.0 Page 13 administration in-house and the contract pharmacist has approved their training. At present no residents self-medicate, although they are encouraged to do so where possible. Ivor Lodge Limited DS0000043227.V252781.R01.S.doc Version 5.0 Page 14 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 Staff give residents satisfactory information about how to complain, although the complaints procedure should also be displayed in the home. Improvements are needed to the home’s vulnerable adults policy. EVIDENCE: The home has a written complaints procedure, which is in the home’s Statement of Purpose and is given to all residents and their representatives on admission. The Owner/Manager said ‘When residents come into the home we got through the complaints procedure and explain it to them. We then encourage them to raise any concerns they might have immediately so we can put things right as soon as possible. I work in the home every day and they know they can come to me about anything, or to any other member of staff.’ It is recommended that the complaints procedure is displayed in the home where relatives and visitors can easily see it. The home has policies and procedures on adult protection and whistle blowing and staff are made aware of these during induction. The policy on adult protection needs improving so that it explains the role of social services when abuse is suspected, ie that they take the lead in an investigation and must be contacted. Ivor Lodge Limited DS0000043227.V252781.R01.S.doc Version 5.0 Page 15 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): EVIDENCE: These Standards were inspected at the home’s previous inspection on 9 June 2005. Ivor Lodge Limited DS0000043227.V252781.R01.S.doc Version 5.0 Page 16 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): EVIDENCE: These Standards were inspected at the home’s previous inspection on 9 June 2005. Ivor Lodge Limited DS0000043227.V252781.R01.S.doc Version 5.0 Page 17 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 The home is well run by the Owner/Manager who is an experienced mental health professional. Residents influence the running of the home. The health and safety of residents and staff is promoted through safe working practices. EVIDENCE: The Owner/Manager has run care homes for 14 years and is a qualified mental health nurse. She has recently completed her BSc Honours in Mental Health Care Professional Practice (which includes a Leadership and Management module). She works in the home full-time and is committed to delivering quality care. All residents interviewed praised the Owner/Mananger and their comments included: ‘I have never seen Sadna lose her temper or get ruffled.’ ‘Sadna hold everything together. She is always here for us.’ ‘Sadna employs some really good staff.’ ‘I’m very fond of Sadna. She is like family to me.’’
Ivor Lodge Limited DS0000043227.V252781.R01.S.doc Version 5.0 Page 18 The Owner/Manager is commended for the quality of her work. Residents influence the running of the home. Meetings are held every Monday for residents to decide the menus and activity programme for the week. Formal residents’ meetings are held every few months. The most recent was on 12.09.05 and 12 residents attended. Minutes showed that medication, fire safety, and keeping the home tidy were discussed. Residents also have a say in major decisions about the home. The conservatory was turned into a smoking room at the residents’ quest. When the home is being redecorated residents choose the colour schemes. Resident involvement in the running of the home is commended. Polices and procedures are in place for safe working practices and the premises are risk assessed. The Fire Officer inspected the home on 15.09.05 and made one recommendation which has been met. The Owner/Manager said the EHO has not inspected the home yet this year Ivor Lodge Limited DS0000043227.V252781.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X 3 X Standard No 24 25 26 27 28 29 30
STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X X X X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Ivor Lodge Limited Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score 4 X 4 X X 3 X DS0000043227.V252781.R01.S.doc Version 5.0 Page 20 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 YA22 Good Practice Recommendations 1 2 YA23 Ivor Lodge Limited DS0000043227.V252781.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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