Inspection on 11/01/06 for Ivy Lodge

This inspection was carried out on 11th January 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ivy Lodge 14/06/06

Ivy Lodge 12/05/05

Ivy Lodge 05/01/05

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Ivy Lodge 212A Howeth Road Ensbury Park Bournemouth Dorset BH10 5NZ Lead Inspector Sophie Barton Unannounced Inspection 11 January 2006 09:00 th Ivy Lodge DS0000062109.V277596.R01.S.doc Version 5.1 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 Ivy Lodge DS0000062109.V277596.R01.S.doc Version 5.1 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. Ivy Lodge DS0000062109.V277596.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Ivy Lodge Address 212A Howeth Road Ensbury Park Bournemouth Dorset BH10 5NZ 01202 593593 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) Acorn Lodge (Bournemouth) Ltd Mr Matthew Druce Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Ivy Lodge DS0000062109.V277596.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The first floor bedroom must only be occupied by an ambulant service user who is able to understand and react to emergency situations including evacuation. The home may accommodate up to six (6) service users where the care home address is their permanent place of residence. A seventh (7th) place is available for a service user who has a permanent place of residence which is not that of the care home and for whom short term respite care is required. 12th May 2005 2. 3. Date of last inspection Brief Description of the Service: Ivy Lodge is owned by Acorn Lodge (Bournemouth) Ltd and Mrs Angela Druce is the Responsible Individual. The Registered Providers Acorn Lodge (BOURENMOUTH) Ltd also own Acorn Lodge a Registered Home for people with learning disabilities. Mr Matthew Druce is the Registered Manager with day-today responsibility for the running and management of Ivy Lodge, which is registered to provide personal care and accommodation for a maximum of seven people. Ivy Lodge is a large detached chalet style bungalow set in pleasant grounds with ample off road parking and turning spaces. The premises comprises two floors however, all the accommodation and communal living areas are on the ground floor except for one bedroom, which is on the first floor. All bedrooms are for single occupancy and all have en suite facilities. There is a separate bathroom on the ground floor. There is a large lounge/dining area and a fully fitted kitchen. The laundry room is sited in the grounds in a separate building. The property has been extensively refurbished and decorated. Access to the property and rear garden involves a small flight of steps however these do not present any difficulties for the current group of residents living at Ivy Lodge. Ivy Lodge is on a main bus route to all parts of Bournemouth and a short walk for the main bus service to Poole. Staffing is provided in the home twenty-four hours a day. Service users are encouraged to maintain their independence, and routines in the home are kept to a minimum. Ivy Lodge DS0000062109.V277596.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection has been undertaken as part of the statutory inspection process in accordance with the Care Standards Act 2000. This was an unannounced inspection on Wednesday 11th January 2006 at 9.00am to 2.00pm. The Registered Manager was present for all of the inspection, as was the Deputy. Three service users were observed in the communal areas of the home and spoken with briefly. The main part of the inspection involved examining service user care files, and discussing care practices with the Manager and Deputy. The inspector also sought feedback about the home from the funding authority that contracts with the home. A number of policies were examined and the inspector had a tour of the building. This inspection focused on 12 key standards. Only three of these were assessed as being met at this inspection. What the service does well: What has improved since the last inspection? The medication policy has been updated and it now covers a wider number of areas ensuring that staff follow appropriate guidance in the recording and administration of medication. The Manager and Deputy have supported service users to have more ownership over their care files, with service users understanding that they are ‘their own’ files and that they can read/look at them when they wish. Ivy Lodge DS0000062109.V277596.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ivy Lodge DS0000062109.V277596.R01.S.doc Version 5.1 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 Ivy Lodge DS0000062109.V277596.R01.S.doc Version 5.1 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): 2 and 3 The home has sufficient documentation of service users’ needs and aspirations, ensuring that they are able to understand and meet their needs well. However, improvement is needed in ensuring that service users’ views and aspirations are obtained and recorded. EVIDENCE: Three care files were examined, including one for a service user who had recently moved into the home in an emergency. The home had appropriately obtained the Care Management Assessment and Care Plan and completed their own assessment as far as was possible. The home has a contract with Bournemouth Social Services who block funds the home’s seven beds. In discussion with Social Services it was confirmed that the home is clear about the needs it can meet and how these need to be compatible with the existing service users. Where the needs of service users have not been able to be met by the home, the Manager has appropriately dealt with this. Service user aspirations are documented in the Essential Life Plan developed for each service user by the home. There is no formal system used for ensuring service users are aware of advocacy support when moving into the home, or for service users and their representatives views to be sought and recorded. Ivy Lodge DS0000062109.V277596.R01.S.doc Version 5.1 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 Care Plans are detailed and informative, ensuring that staff are fully aware of how to meet service user needs and aspirations. However the care planning review systems lack evidence of service user participation and consultation. EVIDENCE: The service users have decorated their folders / care files with pictures and symbols that are said to represent their likes. The Manager also stated that the daily records are written with the service users and that service users take responsibility for taking their files to health appointments where necessary. The home relies on the funding authorities initiating formal reviews each year. There is no system set up for documenting the discussions at these reviews or for liaising with the authority when the review is over due. The Manager stated that the home’s care plan (Essential Life Plans) for the service user is reviewed informally at 6 monthly intervals. Again however there was no record of service views or participation at these reviews, other than a signature of the service user. The Essential Life Plans seen however were detailed, especially in the area of behaviour management and managing risks. Ivy Lodge DS0000062109.V277596.R01.S.doc Version 5.1 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): 15, 16 and 17 The home enables service users to maintain contact with family, and further ensures that service users have safe and appropriate family relationships and friendships. Daily routines and house rules do not allow service users the opportunity to develop their skills in any meaningful way. Service users benefit from mealtimes that are flexible and relaxed, with diets that meet their needs. However, service users are not actively supported to help shop, prepare and cook meals which inhibits real choice and independence. EVIDENCE: During the inspection the inspector observed staff and service users talking about the service users regular contact with family and friends. Daily records also evidenced contact with family and the Manager confirmed that service users are enabled and encouraged to maintain contact with family. Service users are encouraged to socialise with people out of the home. The Manager has been on a personal relationships course. Ivy Lodge DS0000062109.V277596.R01.S.doc Version 5.1 Page 11 The Inspector spoke to the Manager and Deputy at length in relation to the home’s daily routines and living tasks. There are no formal systems or routines set up to ensure service users have the opportunity to develop independence skills within the home. For instance the staff do the home’s weekly shopping rather than service users being enabled to do this. The service users needs in relation to ‘Life Skills’ in not an area that is a focus of the home’s role. However, the Manager did confirm that service users have progressed in this area, and that some service users do help with some household tasks if they wish. Housekeeping responsibilities are not documented on the service users’ plans, and therefore not formally reviewed. The home records the daily meal cooked for service users. This record did not include the breakfast or lunch meals provided for service users, and therefore the inspector was unable to ascertain whether the food provided was adequate. The staff consult with service users once a week about the menu for the forthcoming week. The Manager stated that all service users can verbalise their wishes. Only one choice of meal is provided each evening. Service users preferences for lunch are well recorded and known to staff. Staff do the shopping and cooking of meals, but service users can shop for their own personal food/snacks. The Manager stated that service users can help prepare the meals if they wish. Lunch was observed by the inspector and this was seen to be relaxed and informal, suiting the service users needs and wishes. Care plans identify needs and risks in relation to food, and staff make an appropriate record where issues are highlighted. Ivy Lodge DS0000062109.V277596.R01.S.doc Version 5.1 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): 20 The home’s practice and policies in relation to medication have been improved to ensure that service users are protected and that safe procedures are followed. EVIDENCE: The inspector examined the ‘Medication Administration Records, the home’s medication policy and spoke at length to the Manager and Deputy about the medication systems within the home. The requirements and recommendations following the Pharmacy Inspector visit in September 2005 had been met. The medication policy had been updated. Any hand written changes to the MAR sheet had been signed by another ‘competent’ worker. The Deputy Manager had developed more detailed medication discharge forms, and the MAR sheets now include any allergies or ‘none known’ for each service user. The G.P’s had been sent an updated list of household remedies to be used in the home to sign and agree. Ivy Lodge DS0000062109.V277596.R01.S.doc Version 5.1 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 The complaints procedure and policy needs to be improved to ensure the regulations are met and in order for complaints to be satisfactorily addressed. EVIDENCE: The Manager stated that service users are listened to and encouraged to raise concerns about the home through reviews and resident meetings. However, there was no written documentation of review meetings and resident meetings are infrequent (every 3 months ). The home does have contract meetings with the local authority who funds the current service users. This is a forum where any complaints can be addressed. The inspector spoke to the funding authority and was informed that there has been a recent complaint made relating to food prepared for service users. The home has not formally recorded this complaint. The Manager stated that there have been no complaints made directly to the home and the Commission has not received any complaints about the home. The Inspector examined the complaints policy and it does not state the timescales for when the home will address the complaint and does not refer to the fact that the Commission can be contacted at any stage of the complaint. Ivy Lodge DS0000062109.V277596.R01.S.doc Version 5.1 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): None EVIDENCE: These standards were not assessed at this inspection. Please refer to the previous report in May 2005 that stated that the key standards were met. Ivy Lodge DS0000062109.V277596.R01.S.doc Version 5.1 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): 33, 34, and 36 Staff competence and the hours provided in the home would benefit from being reviewed to ensure it meets the needs of the residents. Staff recruitment practices need to be improved, to ensure all persons employed are appropriate and safe to work with service users. The supervision of staff lacks formality and purpose, which again can have a negative impact on the outcomes for service users. EVIDENCE: The Inspector examined the working rota. The rota showed that there are two staff on each shift, including two waking night staff. The night shifts start at 8pm and therefore restricts the opportunities for service users to take part in outside evening activities. A comment received from health and social care professionals stated that there are on occasions staff on duty whose English language is limited. This is especially relevant to evening shifts. These areas will be monitored at the next inspection. Three staff files were examined. Two of these staff were from overseas. Since the inspection the Registered Provider has forwarded the inspector copies of the workers CRB checks. There was however no copies obtained of the student or work visas. Application forms had been completed and two references Ivy Lodge DS0000062109.V277596.R01.S.doc Version 5.1 Page 16 obtained. The Inspector noted that some references were limited in detail, and were not completed by managers, but colleagues or personal references. One worker had started work prior to a CRB check being received. The rota showed her working supernumerary but did not record what member of staff was responsible for the supervision. A POVAFirst check had been made, but no date or record kept of when this check was initiated/completed. There was no record made of the reasons for gaps in employment for two of the staff recently employed. Staff had been provided with a contract /statement of terms and conditions. Staff had also been subject to appraisals. Supervision records did not state the date of the supervision and the recording was limited to noting down training requests. The Deputy commented that a new form has been devised and will be put into practice this month. However, this form was again inadequate and did not include a section for noting down the discussion relating to the monitoring of work with individual service users. Ivy Lodge DS0000062109.V277596.R01.S.doc Version 5.1 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): 39 The home has insufficient quality assurance systems, and no formal monitoring systems. Service users and representatives are not receiving appropriate feedback on the homes quality of care and development plans. EVIDENCE: The Manager arranges for service users and their representatives to complete a questionnaire yearly in relation to the quality of care provided by the home. The completed questionnaires are made available to visitors to the home. The Manager confirmed that at the service user’s annual review, the views of all interested parties are sought on how the home is achieving goals for service users but these discussions and outcomes are not recorded. The Manager does not formally collate the views of others, and no annual development plan is produced which reflects the aims and outcomes for service users. There is also no formal monitoring of the home by the Responsible Individual. No evidence was provided to show that the Responsible Individual had completed monthly visits to monitor the home, and the Commission had not received any Regulation 26 reports outlining the Responsible Individuals assessment on the conduct of the home. Ivy Lodge DS0000062109.V277596.R01.S.doc Version 5.1 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 2 3 3 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 1 23 x ENVIRONMENT Standard No Score 24 x 25 x 26 x 27 x 28 x 29 x 30 x STAFFING Standard No Score 31 x 32 x 33 2 34 1 35 x 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 x x x x LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x x 3 x x x 1 x x x x Ivy Lodge DS0000062109.V277596.R01.S.doc Version 5.1 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 The home must amend its complaint procedure to include the timescales for when a complaint will be dealt with, and to confirm that the Commission can be contacted at any stage of the complaint. A record of all complaints made about the care provided by the home must be recorded appropriately. Staff records must include a copy of a passport, birth certificate, and copies of work visas where appropriate. The Responsible Individual must complete monthly monitoring visits to the home and supply the Commission with the monthly report. Timescale for action 1 YA22 22 05/03/06 2 YA34 19 05/03/06 3 YA39 26 05/03/06 Ivy Lodge DS0000062109.V277596.R01.S.doc Version 5.1 Page 20 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 YA2 YA6 YA16 YA17 Good Practice Recommendations The home should ensure that service users views are ascertained in relation to moving into the home, about their assessment of needs and inform service users of advocacy support. Service users’ views should be sought and recorded when reviewing their care plan. The daily routines in the home should allow for service users to be more independent with day-to-day living tasks. Service users’ responsibility for housekeeping tasks should be specified in their individual plans. More opportunity should be provided for service users to shop, prepare and cook their own meals. The manager should ensure that the staff team reflects the cultural and gender composition of service users, and can communicate effectively with service users and their representatives. The staff hours provided should be reviewed to ensure it meets the needs of service users. The date of when the POVA First check was received should be recorded, or the email obtained. The Registered Manager should be familiar with the latest CRB guidance. When staff start work in the care home prior to a satisfactory CRB check being received there should be clear records made of who is responsible for supervising the worker on each shift. Any gaps in the workers employment record needs to be explored and documented. Supervision of staff should include the monitoring of the individual’s work with service users and support and professional guidance. There should be a clear record of the date of supervision. There should be an annual development plan for the home made available to the Commission and to other interested parties. A record should be kept of the discussions and outcomes following service user statutory reviews. DS0000062109.V277596.R01.S.doc Version 5.1 Page 21 1. 2. 3 4 5 YA33 6 YA34 7 YA36 8 YA39 Ivy Lodge Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ivy Lodge DS0000062109.V277596.R01.S.doc Version 5.1 Page 22 - 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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