Inspection on 11/09/06 for Jordan Lodge

This inspection was carried out on 11th September 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 found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Jordan Lodge 08/11/07

Jordan Lodge 08/12/05

Jordan Lodge 04/08/05

Jordan Lodge 27/01/05

Jordan Lodge 15/07/04

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

CARE HOME ADULTS 18-65 Jordan Lodge 5 Warham Road South Croydon Surrey CR2 6LE Lead Inspector David Halliwell Key Unannounced Inspection 11th September 2006 09:30 Jordan Lodge DS0000025803.V311172.R02.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 Jordan Lodge DS0000025803.V311172.R02.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. Jordan Lodge DS0000025803.V311172.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Jordan Lodge Address 5 Warham Road South Croydon Surrey CR2 6LE 020 8686 8801 020 8668 3212 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) Laurel Residential Homes Limited Mr Jeremy R Burrows Care Home 14 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (14) of places Jordan Lodge DS0000025803.V311172.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th December 2005 Brief Description of the Service: Jordan Lodge is a large detached building in South Croydon, well situated for access to the centre of Croydon and its many community based facilities, and good transport links. The property comprises of 2 day rooms (lounge and dining area) on the ground floor, and a small coffee/smoking room on the first. There are 14 single bedrooms, all fitted with hand basins but no other en-suite facilities. There are 3 WCs, 3 bathrooms and 1 shower. Off-street parking is provided to the front of the house, while there is a large, pleasant garden at the rear. The stated aim of the home is to provide care for people with longterm mental health problems and with the dual diagnosis of mental health and substance misuse problems. The standard fees of a placement are £666 per week and £735 for a dual diagnosis placement. Jordan Lodge DS0000025803.V311172.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection visit undertaken by the new Inspector responsible for Jordan Lodge. The Inspection covered all the key standards and involved a tour of the home, a review of all the homes records and formal interviews with 3 staff and 2 service users. Informal interviews were conducted with 2 other Service Users as a part of the tour of the home. There were no requirements outstanding from the last inspection. 2 new requirements and 4 recommendations have been made as a result of this inspection and feedback on all these requirements and recommendations was given verbally to the Manager at the end of the inspection visit. The Inspector found the residents and staff very helpful and they are to be thanked for the assistance that they gave him over the course of this inspection visit. The Inspector was impressed by the commitment and enthusiasm of the Manager and of the staff group. The Manager informed the Inspector that the standard fees for a residential placement at this home are £666 per week. What the service does well: What has improved since the last inspection? All the requirements and recommendations have been met since the last inspection. Jordan Lodge DS0000025803.V311172.R02.S.doc Version 5.2 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. Jordan Lodge DS0000025803.V311172.R02.S.doc Version 5.2 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 Jordan Lodge DS0000025803.V311172.R02.S.doc Version 5.2 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): 1, 2 & 4. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Prospective service users are provided with sufficient and useful information which will help them to make an informed choice and that they will be provided with a positive opportunity to visit and test drive the home before they make any decision to move there. They can also be assured that their individual needs and aspirations will be assessed appropriately before and after admission to the home. EVIDENCE: Standard 1 – The Statement of Purpose and the Service User Guide were revised and updated in May 2006. The Registered Manager gave copies of both these documents to the Inspector. On inspection the Inspector found that the information provided in these documents is appropriate and relevant to their purpose. Both provide prospective service users with the information that they need to make an informed choice about where to live and both will also assist placing authorities in making appropriate placement decisions based on sufficient and relevant information for their service users. Standard 2 – The Inspector reviewed 5 of the current 12 residents files and also interviewed formally 2 service users and 3 service users informally. The Inspector also interviewed 2 members of staff as well as having detailed discussions with the Manager. A comprehensive pre-admission assessment Jordan Lodge DS0000025803.V311172.R02.S.doc Version 5.2 Page 9 which covered most of the service users needs was found on file for each service user file inspected. Service users with whom the Inspector spoke to agreed that they had been fully involved with the assessment process and that their views and wishes had been taken into account in the process. Standard 4 – On the day of inspection a prospective service user was visiting the home as a part of his being able to decide whether he wished to move into Jordan Lodge as a part of his care plan. He informed the Inspector that he had had several pre-admission visits and had been able to discuss any points he had required clarification of with the Manager, the staff and the other residents. He now feels very positive about the home and a potential to move into Jordan Lodge and decided on the day to accept the offer that had been made to him of a placement there. The Manager informed the Inspector that he will be offered a trial period which will be reviewed to see how well his needs are being met and how he feels about his placement there after 3 months. Prospective service users do have an opportunity to visit and to test drive the home and certainly this prospective service user had found it most helpful in making a decision to live there. Jordan Lodge DS0000025803.V311172.R02.S.doc Version 5.2 Page 10 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 from evidence gathered both during and before the inspection visit to this service. With the introduction of a new and effective care planning structure service users will be assured that their assessed and changing needs and personal goals are likely to be much better met than has previously been the case. Service users are being helped to make decisions about their own lives with assistance and support and this new structure for the delivery of care assists in this process. It is also enabling service users and their support staff to work on taking calculated risks as a part of developing a more independent life style. EVIDENCE: Standard 6 – Schedule 3 of the National Minimum Standards sets out clearly the requirements for a service user plan that should be in place for each resident of the home. The Inspector reviewed 5 of the current 12 residents files and also interviewed formally 2 service users and 3 service users informally. The Inspector also interviewed 2 members of staff as well as having detailed discussions with the Manager. Jordan Lodge DS0000025803.V311172.R02.S.doc Version 5.2 Page 11 The Manager explained to the Inspector about a new care planning structure that is just being implemented at Jordan Lodge in order to better meet the assessed needs of the residents. In 2 service user files inspected the new format / structure was evidenced and is in place, it is clear to the Inspector that this is a very effective model which will help the delivery of effective and appropriate care for each of the residents. The input of the service user is integral to the care planning structure and to the review and monitoring of the delivery of care plan objectives, which is made much easier by this process. The service user plan includes rehabilitation and specialist needs, social and health care needs, diet, mood, sleep, medication, the support required by service users, the goals and aspirations of service users and care plan objectives are prioritised according to the needs of the service user and supported by action plans that can be monitored and reviewed. The Manager explained that it is the intention to have this new model in place for each of the residents in the near future. In the 3 other service user files inspected the new model is not yet in place and the care planning process being used is clearly less effective than the new model. Up to date care plans and reviews were not evidenced on the other 3 files inspected although the daily activities book goes some way in ensuring that service users activities are appropriate and meets their needs. From the review of resident’s files healthcare needs are not at present and must in future be identified in the care plans. It is required therefore that the implementation of the new care planning structure is progressed for all service users as speedily as is possible and that staff are provided with training in order to make best use of the new structure of care planning, delivery, monitoring and review. With this in place service users will be fully assured that their assessed and changing needs and personal goals will be reflected in their individual plans. Standard 7 – At the time of the inspection the Inspector saw that staff were respecting the rights of the service users in the home to make their own decisions on a number of issues. A residents meeting was held with service users to discuss issues about the home and residents were seen by the Inspector to be able to make choices about what they want to eat and about their daily activities. A residents meeting book is being used to record the monthly meetings and logs all the decisions made. In addition to this residents confirmed to the Inspector that they are encouraged to make decisions within the home and that their wishes are respected and that they do feel listened to by staff. Standard 9 – Risk assessments were seen on the residents files inspected both as a pre-admission assessment tool and also following admission being used to assist service users to be appropriately supported to take risks as a part of Jordan Lodge DS0000025803.V311172.R02.S.doc Version 5.2 Page 12 developing a more independent lifestyle wherever possible. These risk assessments are agreed with the service user and the relevant professionals. So service users can be assured that they will be supported to take risks as part of developing a more independent lifestyle wherever this is possible. Jordan Lodge DS0000025803.V311172.R02.S.doc Version 5.2 Page 13 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 from evidence gathered both during and before the inspection visit to this service. Service users may feel assured that they will be able to take part in appropriate activities within the local and wider community. They will be supported in maintaining and developing appropriate relationships and that their rights and responsibilities will be respected in their daily lives. They are also assured that they will be offered a healthy diet. EVIDENCE: Standard 12 – The Manager showed the Inspector the daily activities book that records the activities of each resident and links this with their care plan objectives or service user plans. The care plan objectives identify activities for each resident that are appropriate to their age and cultural needs. Residents interviewed by the Inspector said that they feel that they participate in the activities they wish to do and no service user said that they wanted to do an activity but were not allowed to do so or were not enabled or supported by staff to do so. The actual range and scope of activities undertaken by the Jordan Lodge DS0000025803.V311172.R02.S.doc Version 5.2 Page 14 service users however is limited by the extent of the resident’s mental well health and wishes at the time. The cultural needs of all residents are assessed and the Inspector saw evidence of this on a number of service user files. One ethnic minority resident’s needs to do with food and religion were identified on the needs assessment held on file and the Manager informed the Inspector that guidance is provided for staff in order to support those needs. Staff interviewed confirmed that they found this support helpful. The Manager informed the Inspector that information about local community activities is regularly obtained and distributed to the residents. Service users told the Inspector that they found this information useful. Standard 13 – The central location of the home makes access for service users to public transport easy and all the service users interviewed said that this is how they get out and about to go shopping or to see their friends and families. Some service users said that they do go to church and make use of day centre provision in and around Croydon. When the Inspector asked residents about going to cinema or theatres they were less than enthusiastic about using these forms of entertainment. The Manager informed the Inspector that all residents are registered to vote and are encouraged to use their votes. Service users confirmed with the Inspector that they are supported and enabled to vote although some residents said that they are not inclined to use their votes given the state of politics at present. Standard 15 – Interviews with service users confirmed that in many cases they do maintain regular contact with members of their families and either go out to visit their relatives or receive them at Jordan Lodge. Staff interviewed by the Inspector said that they encourage these visits and are sometimes involved in helping their resident’s sort out difficulties that they experience their relationships with their relatives as this often has a direct bearing on the mental well being or not of the resident. Visitors to the home are encouraged and use the visitor’s book to sign in. The Inspector saw information made available within the home about local activities for residents to take up if they wish. Standard 16 - Policies seen by the Inspector to be established within the unit ensure that service users rights to privacy, respect and dignity are respected. Residents who were interviewed also confirmed that they felt staff respected these rights. Residents said that they have a key to their own bedrooms, their mail is unopened, their preferred form of address is used by staff and staff do knock Jordan Lodge DS0000025803.V311172.R02.S.doc Version 5.2 Page 15 on their doors before entering. The Inspector observed staff to be interacting with residents in a friendly and respectful manner. Interviews both with staff and residents confirmed that residents participate in household chores as a part of the rehabilitative process and this participation was seen to be supported in residents care plans. There is a specific area for smokers and there are appropriate policies regarding drug and alcohol taking on the premises. Standard 17 – Food menus shown to the Inspector indicate that menus are varied, choices are provided and that service users assist in the drafting of the food menus. No complaints about the meals arose during the inspection in fact all those service users interviewed said that like the food provided at Jordan Lodge. It was noted that a wide range of meals were listed which cater for the multicultural needs and wishes of the residents. The Inspector asked the Manager if a dietician is used to advice on the menu planning in order to ensure that the food provided is always healthy and nutritious. The Manager said that a dietician is used in some cases where there is a specific need but not as a general rule. The Manager showed the Inspector a detailed food record that is kept for each resident and that is useful to help ensure that the service users maintain an appropriate diet that is healthy and nutritious. However it is recommended that a selection of seasonally fresh fruit is made available for residents from the kitchen during the day. Jordan Lodge DS0000025803.V311172.R02.S.doc Version 5.2 Page 16 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 from evidence gathered both during and before the inspection visit to this service. Personal and healthcare is provided according to service users individual needs. Clinical support for specific health care is provided by General Practitioners, District Nurses and by the psychiatric multi disciplinary teams as well as other specialist services such as chiropody, sight and hearing services thus ensuring that residents do have a good quality of life. EVIDENCE: Standards 18 & 19 – Service users interviewed confirmed that they receive their care in the way they prefer. They confirmed that they are able to decide themselves about their daily routines and care staff interviewed by the Inspector also confirmed this. Service users confirmed that they keep in regular contact with their General Practitioner and psychiatric team. The Manager informed the Inspector that all the residents are registered with dentists, opticians, chiropodists and community nurses in order to maintain their all round good health. Residents interviewed were able to confirm this, as well as their case files, which evidence it by the recording of their contact with these services. It was also confirmed that annual healthcare checks are routinely carried out by GPs. Jordan Lodge DS0000025803.V311172.R02.S.doc Version 5.2 Page 17 Standard 20 – The home’s policies and procedures manual contains appropriate policies for the control of medication. The Inspector reviewed the records for the administration of medication to residents and these were seen to be appropriately completed and in line with the home’s policies and procedures. Training in medication for staff is a part of the agencies training plan and the 2 members of staff interviewed said that they had received this training. Service users vary in their ability to administer their own medication. The home actively supports service users who wish to self medicate, otherwise trained staff organise the ordering, the storing and the administration of medication with service users. Jordan Lodge DS0000025803.V311172.R02.S.doc Version 5.2 Page 18 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 from evidence gathered both during and before the inspection visit to this service. Service users are protected from abuse, neglect and self-harm by the policies and procedures of the home. All staff should receive regular training in the protection of adults from abuse. EVIDENCE: Standard 22 – Both the 2 service users interviewed formally by the Inspector and 2 service users spoken with more informally, confirmed that they feel their views are listened to and acted upon. They all said that if they had a complaint they know the procedure to be followed and would do so if they needed to. Staff interviewed confirmed with the Inspector that the residents were all aware of the complaints process and that the whole staff group took any issues raised by residents seriously. The Inspector reviewed the homes’ complaints record and no complaints had been made since the last inspection visit. Standard 23 - The home has an adult protection policy and the Manager informed the Inspector that staff all have access to training for POVA. One of the two staff interviewed by the Inspector had attended the training the other had not. It is recommended that all staff undertake POVA training at least once every two years from an authorised trainer. The Inspector saw the allegation of abuse record; no allegations had been made since the last inspection. The Manager confirmed this to the Inspector. Jordan Lodge DS0000025803.V311172.R02.S.doc Version 5.2 Page 19 The policies and procedures manual for the home includes a whistle blowing policy and a policy on dealing with violence and aggression. Understanding the policies and procedures is a part of the staff induction process and evidence was seen on file that staff are asked to sign to say that they have read and understood the policies and procedures for the home. However not all policies and procedures had been signed by all staff to say that they have read and understood them. It is recommended that all staff are asked to sign all the homes policies and procedures. The home does look after resident’s money and the Inspector reviewed the financial records for these transactions that were in order. All transactions are dated and signed for by both staff and residents to confirm satisfaction by all parties. The Inspector found no anomalies. An inventory of resident’s belongings is kept up to date by key workers for all residents’ belongings that are kept in their bedrooms and this is important since it helps to ensure the appropriate protection of residents personal property. Jordan Lodge DS0000025803.V311172.R02.S.doc Version 5.2 Page 20 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 from evidence gathered both during and before the inspection visit to this service. Service users can be assured that the home is safe, comfortable, clean and hygienic. EVIDENCE: Standards 24 & 30 - The Inspector reviewed all areas of the home to assess the quality of the environment and décor. The home was found to be generally clean and hygienic, free from offensive odours and safe. Routine maintenance is carried out for the property on a regular basis and this is evidenced with the good state of repair and condition of the home. The Inspector undertook a tour of all the rooms in the home together with the Manager. 5 resident’s bedrooms were inspected with the permission of those residents. They all told the Inspector that they are happy with their rooms. Jordan Lodge DS0000025803.V311172.R02.S.doc Version 5.2 Page 21 The Manager informed the Inspector that the last fire risk assessment was undertaken in November 2005 and all the risks identified have been addressed. The homes fire alarm is serviced every 3 months and the last check in July 2006 showed that everything was satisfactory. The Inspector saw the report. Evidence was shown to the Inspector by the Manager that the home’s fire fighting equipment was tested as satisfactory in May 2006. Similarly the emergency lighting systems were tested in April 2006 and were found to be satisfactory. Evidence of the last LFEPA visit was seen to have been carried out in January 2006 tests revealed everything as being satisfactory. The last environmental health officers’ report was completed in November 2005 and all the recommendations had been met at the time of this inspection visit. The Inspector asked to see the weekly records for checks on water temperatures and the Manager provided the homes records for this. They revealed that these tests have been carried out each week as is required. Tests carried out all indicated that the hot water temperatures were within 45 degrees Celsius. A pest and hygiene test was carried out in February 2006 satisfactorily. Jordan Lodge DS0000025803.V311172.R02.S.doc Version 5.2 Page 22 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 & 36. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Service users can be confident that a competent and appropriately qualified staff team is supporting them. Also that their needs will be met by appropriately trained staff. When arrangements are fully in place for the formal supervision and appraisal of staff service users will be able to be fully confident that they will benefit from a well supported and supervised staff group. EVIDENCE: Standard 32 – Over the course of this inspection visit to Jordan Lodge, the Inspector saw that staff acted in a friendly and approachable manner to residents, taking time to deal with service users questions in a sensitive and thoughtful way. As part of the inspection the Inspector reviewed all of the staffing files for Jordon Lodge and interviewed 1 member of the care staff, the Deputy Manager and the Manager. The Manager informed the Inspector that as a part of the induction process all staff are issued with job descriptions and are asked to read and discuss the homes policies and procedures. The Inspector on staff files and from discussions saw evidence of this with staff interviewed. Staff have copies of the Jordan Lodge DS0000025803.V311172.R02.S.doc Version 5.2 Page 23 General Social Care Standards / Code of Conduct. Volunteers are not used within the home. The Manager told the Inspector that he holds an NVQ level 4 qualifications, as does his Deputy Manager. 3 staff have just completed their NVQ level 2 training and are awaiting receipt of their NVQ certificates. 2 other care staff are registered to undertake their NVQ level 2 qualifications this autumn. Staff interviewed confirmed this information with the Inspector. Standard 34 - With reference to the organisations recruitment policy staff files evidenced that suitable application forms are completed, that 2 references are obtained including one from the last employer. All staff files reviewed by the Inspector evidenced that proper CRB checks have been carried out for staff employed within this unit. Equally that all other documentary evidence required to be gathered for staff was seen to be held on the staff files reviewed. Staff interviewed confirmed that all have a contract of employment and that they understand their terms and conditions as well as their roles and responsibilities within the home. Standard 35 - The Manager informed the Inspector that there is an overall training and development plan and budget for the 3 units that make up the Laurel Group of Homes. Disaggregating the information specifically for Jordan Lodge was not possible. There is a person responsible for the training and development of staff. The Manager informed the Inspector that a structured induction programme is offered to new staff and documentary evidence of this was seen by the Inspector and supported at interview by staff. Standard 36 - At present staff receive ongoing support in the work they undertake but they do not receive 1:1 supervision which includes the: • Translation of the homes philosophy and aims into working with individuals, • Structured monitoring of work with individual service users and the analysis of care plan outcomes, • Support and professional guidance, and the • Identification of training and development needs, • Annual appraisals. The Manager has informed the Inspector that this form of supervision is being planned now for implementation in the near future. This is welcomed since structured supervision together with implementation of the new care planning model and appropriate staff training will assist the Manager in monitoring and reviewing the effectiveness of the care service. The Inspector is advised that Jordan Lodge DS0000025803.V311172.R02.S.doc Version 5.2 Page 24 all staff will receive this form of structured supervision at least once every 2 months and this is a requirement. The Manager has informed the Inspector that annual appraisals have just started to be undertaken for staff in the unit and evidence of this was seen in 2 of the staff files for annual appraisals having been completed for 2006. Processes used for both supervision and appraisals should be closely linked as together they form a useful tool in the effective management of staff. Jordan Lodge DS0000025803.V311172.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 & 42. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Service users can be confident that they benefit from a well run home. When the full quality assurance system is in place they will also be able to be confident that their views underpin monitoring and review of the homes developments. Service users may also be confident that their rights and best interests are safeguarded by the home’s record keeping policies and procedures. EVIDENCE: Standards 37 – The Manager of Jordan Lodge has been in place for several years now and is an experienced manager. As already said previously he holds an NVQ level 4 and his Deputy Manager has now also successfully achieved her NVQ level 4 certificate. The service users spoken to by the Inspector all felt that the home is being well run and evidence seen by the Inspector supports this view. The homes records and administration systems were seen by the Jordan Lodge DS0000025803.V311172.R02.S.doc Version 5.2 Page 26 Inspector to be in good order and overall the impression was very positive. Interviews with staff reflected a positive and caring approach towards the residents and implementation of new methods for needs assessments and care planning as well as for the development of a new quality assurance system impressed the Inspector that innovative and effective ways of working are being employed within this home. Service users can therefore be assured that they are benefiting from a well run home. Standard 39 - The Inspector was provided with a copy of the home’s development plan for the year ahead which shows the plans for a complete training audit of all staff needs and for the implementation of the new care planning model. The Manager informed the Inspector that when this audit or training needs analysis is completed, staff will then be provided with training in the areas identified as a need. In the medium term this should ensure that all staff are fully and appropriately trained and service users will benefit from this in their experience of receiving care. A quality assurance audit covering a wide range of care provision issues has also been undertaken for the Laurel Group of Homes that includes Jordon Lodge. The clear intention is to improve the effectiveness of the care being provided in order to better meet the needs of service users. The Manager informed the Inspector that the audit will be carried out for each home and an associated action plan put into operation in order to meet the identified needs that the audit identifies. The Inspector suggested to the Manager that feedback questionnaires should also be given to families and referring professionals about identified areas of care provision. Together with the existing feedback sheet used with service users and the new QA audit this should provide very good quality information that can then be used to develop and improve on an annual basis the standard of care being provided at Jordan Lodge and the other Laurel Homes. It is therefore recommended that feedback information sheets be used to gain feedback from relatives and referring professionals to compliment the existing and proposed feedback methods described above. When the above processes have all been implemented service users will be able to be fully confident that their views underpin all self-monitoring, review and developments undertaken by the home. Standard 42 – The Inspector was shown an up to date and satisfactory risk assessment for the building that identified all the risks and actions required to deal with them. Information was seen in the office to do with relevant Health and Safety legislation. Policies and procedures were also seen for Health and Safety, risk assessment, moving and handling and fire. The Manager informed the Inspector that all staff receives training in moving and handling, fire safety, Jordan Lodge DS0000025803.V311172.R02.S.doc Version 5.2 Page 27 first aid, food hygiene, and infection control. This was supported by staff interviewed that confirmed that they had received training in these areas. The Inspector for saw up to date certificates: Boiler / gas Fire alarms Fire extinguishers. An accident record book is being used at the home to record any accidents to staff although nothing had been recorded since the last inspection. The Inspector saw records for: Weekly fire alarm tests Fire extinguisher checks Emergency lighting tests. At the time of this inspection no fire doors were seen to be wedged open and the building appeared to be secure. Jordan Lodge DS0000025803.V311172.R02.S.doc Version 5.2 Page 28 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 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 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 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 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 2 X 3 X X Jordan Lodge DS0000025803.V311172.R02.S.doc Version 5.2 Page 29 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. 1. Standard YA6 Regulation 12 Requirement That the implementation of the new care planning structure is progressed for all service users as speedily as is possible and that staff are provided with training in order to make best use of the new structure of care planning, delivery, monitoring and review. That all staff will receive this form of structured supervision at least once every 2 months. Timescale for action 01/01/07 2. YA36 18 01/10/06 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. Refer to Standard YA17 YA23 YA23 Good Practice Recommendations That a selection of seasonally fresh fruit is made available for residents from the kitchen during the day. That all staff undertake POVA training at least once every two years from an authorised trainer. That all staff are asked to sign all the homes policies and procedures. DS0000025803.V311172.R02.S.doc Version 5.2 Page 30 Jordan Lodge 4. YA39 That feedback information sheets be used to gain feedback from relatives and referring professionals to compliment the existing and proposed feedback methods described above. Jordan Lodge DS0000025803.V311172.R02.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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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