Inspection on 08/11/07 for Jordan Lodge

This inspection was carried out on 8th November 2007.

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

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

Other inspections for this house

Jordan Lodge 11/09/06

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 8th November 2007 09:30 Jordan Lodge DS0000025803.V350903.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Jordan Lodge DS0000025803.V350903.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Jordan Lodge DS0000025803.V350903.R01.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 F/P 020 8688 3212 jeremy.burrows@mac.com 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.V350903.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th September 2006 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.V350903.R01.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 of the service at 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 4 staff and the Manager and 5 of the residents at Jordan Lodge. The Manager informed the Inspector that the Deputy Manager will be leaving the home this December. She will be missed. No requirements have been made as a result of this inspection. 2 good practice recommendations have however been made. Feedback on these recommendations was fully explained to the Manager and to both the Proprietors at the end of the inspection visit. The Inspector found the residents and staff most helpful and they are to be thanked for the assistance that they gave him over the course of this inspection visit. The Inspector was very impressed by the commitment and enthusiasm of the Manager and of the staff group and of the quality of the services being provided at Jordan Lodge. What the service does well: The home is able to demonstrate that it is assessing and meeting the needs of service users admitted to the home. Prospective service users, their relatives and friends are able to visit and to assess the quality, facilities and suitability of the home. The health and social care needs of service users are being well met. Service users are living in a safe, well-maintained environment, with access to safe and comfortable facilities. Service users presented as being well settled and very happy in their environment and satisfied with the staff, their care support and the communal and personal facilities provided. Jeremy Burroughs is managing the home in an open, professional and competent manner. Jordan Lodge DS0000025803.V350903.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Jordan Lodge DS0000025803.V350903.R01.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.V350903.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 2 & 5 were inspected at this inspection. Quality in this outcome area is excellent. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Prospective service users may be fully assured that their needs are assessed and that their individual aspirations and wishes will be taken into account in the assessment process. Each service user has an individual written contract and is provided with a copy. EVIDENCE: Standard 2 – Since the last inspection 5 new residents have been admitted and the home now has a total of 14 residents living at Jordan Lodge. The Inspector reviewed the files of the 4 residents and found that all had received a full and comprehensive pre-admission needs assessment that was carried out with skill and sensitivity by Jordan Lodge staff to the needs of the people concerned. The Manager also told the Inspector that staff ensure a needs assessment and care plan is obtained from the referring authorities for each new resident. Evidence of this was seen by the Inspector on the resident’s files in the form of Care Programme Approach (CPA) documentation. For existing residents staff at Jordan Lodge have requested the clinical teams to update and revise older CPA report documents. Response letters from the Community Mental Health Teams Jordan Lodge DS0000025803.V350903.R01.S.doc Version 5.2 Page 9 involved were also seen by the Inspector setting review dates for these residents. The combined information from both sources form a comprehensive information base for each resident from which accurate and relevant care plans can be drawn up. The Manager explained to the Inspector that the needs assessment process is about ensuring that staff can meet the identified needs of the prospective resident in that they have the appropriate skills, training and knowledge to enable them to do so. Before agreeing admission to Jordan Lodge the Manager allocates a key worker to each resident who will work with them on developing the home’s care plan and making sure it meets the identified needs. Residents concerned were seen by the Inspector to have been involved in the assessment process having had the opportunity to express their wishes and preferences and to comment on their identified needs. Signatures of the residents were seen on the assessment paperwork confirming their involvement in the process. Standard 5 – Each resident’s file inspected contained a written and costed contract which specified all the terms and conditions as set out under Standard 5 of the National Minimum Standards. The Manager is reminded that these contracts will need to be renewed each year. Jordan Lodge DS0000025803.V350903.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7, & 9 were inspected at this inspection. Quality in this outcome area is excellent. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Residents may be assured that their assessed and changing needs and personal goals will be reflected in their care plans. They may also be assured that they will be able to make decisions about their daily lives and be enabled to take risks as part of developing a more independent lifestyle with support, as they need it. EVIDENCE: Standard 6 – At the last full inspection in September 2006 the Manager explained to the Inspector about a new care planning structure that had recently been started at Jordan Lodge in order to better meet the assessed needs of the residents. It was clear to the Inspector at the time that this was a very effective model which would help the delivery of effective and appropriate care for each of the residents. The expressed intention of the Manager was to Jordan Lodge DS0000025803.V350903.R01.S.doc Version 5.2 Page 11 have this new model in place for each of the residents in the near future. A requirement was made following that inspection that the implementation of the new care planning structure be progressed for all service users as speedily as is possible and that staff be provided with training in order to make best use of the new structure of care planning, delivery, monitoring and review. Through the course of this inspection it became clear to the Inspector that this requirement has been met and the new care plans are now in place at Jordan Lodge. The central focus of the services provided at Jordan Lodge are on the residents and how their needs, wishes and preferences can be most effectively be met where-ever possible. Residents were seen by the Inspector to be fully involved in the needs assessment and care planning processes. Care plans seen by the Inspector were based on the needs assessments that had been drawn up both from the Care Programme Approach needs assessment and Jordan Lodge’s own needs assessment. Inspection of the care plans seen by the Inspector evidenced this and the Inspector was impressed with the quality of the care plans seen. They had been clearly divided into sections (relating to the identified needs) with care plan objectives and action plans which addressed the needs and set out identified milestones, so that clear monitoring and review could then be achieved. Regular reviews by the care staff team were evidenced on the files and involvement of each of the residents in these reviews was also evident. They confirmed their involvement in the review and care planning process at interview that was a part of the inspection process. Inspection of the review reports showed that changing needs of service users had been identified and that appropriately revised care plan objectives had been drawn up together with the service user. Key workers were seen to actively provide 1:1 support; to revise the care plans as necessary and to keep the residents informed. Formal 6 months reviews are planned and held with the clinical teams and the residents. The residents at Jordan Lodge who the Inspector spoke to have their own key workers and the Manager told the Inspector that residents can choose their key workers if they wish. Residents confirmed to the Inspector that they are happy with their key workers and find them helpful, supportive and friendly. Standard 7 – Over the course of this inspection the Inspector saw that staff asked residents what they wanted to do and to make decisions about their daily lives. The Manager told the Inspector that residents do have their own residents meetings and that they are minuted. The minutes of these meetings were Jordan Lodge DS0000025803.V350903.R01.S.doc Version 5.2 Page 12 shown to the Inspector by the Manager. The records show that meetings are held regularly, they indicate who has attended the meetings and what issues have arisen and been discussed. Standard 9 – The care planning process includes the use of risk assessments that were seen and inspected on each of the resident’s files. They are evidently used as a pre-admission assessment tool and following admission, being used to assist residents to be appropriately supported to take risks as a part of developing a more independent lifestyle wherever possible. Any identified risks are managed positively to help the residents lead the sort of lives they aspire to as much as is realistically possible. These risk assessments are agreed with the resident and the relevant professionals. So residents 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.V350903.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15, 16 & 17 were inspected at this inspection. Quality in this outcome area is excellent. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Service users may be assured that they will be able to take part in appropriate activities, some of which will be based in the local community. That they will be supported to maintain appropriate personal relationships with family and friends; and that their rights will be respected and their responsibilities recognised in helping them to construct an appropriate programme of activities in their daily lives. EVIDENCE: Standard 12 – The Manager told the Inspector that in order to ensure that each resident is involved in daily activities appropriate to their needs and wishes, the staff at Jordan Lodge maintain daily activities board in the main office. This records the activities of the residents and links them with their care plan objectives and what they say they want to do. Inspection of 5 of the resident’s files show that the resident’s care plan objectives do identify Jordan Lodge DS0000025803.V350903.R01.S.doc Version 5.2 Page 14 activities that are appropriate to the resident’s age and cultural needs. Residents interviewed by the Inspector said that they participate in the activities they wish to do. Residents told the Inspector that if they wanted to do an activity, staff support them to do so. The actual range and scope of activities undertaken by the service users however is limited by the extent of the resident’s mental well health and wishes at the time. The Manager told the Inspector that as a part of trying to maintain continuity for the residents in their daily lives and to support their rehabilitation, where ever possible previous interests, pastimes, hobbies and relationship are encouraged and are built into the daily activities plan for residents. As a part of the care plan review it was evident that significant relationship links for the residents are recorded in the care plans and that the importance for the residents of these links is not underestimated. Resident are encouraged to maintain their relationships and visitors are made welcome when they come to the home. Information about local activities was seen on the notice boards within the home and staff who were interviewed by the Inspector said how they will support residents, in their capacity as care support workers, to take as much of an active role in the community as is appropriate for residents. One resident told the Inspector that he had expressed a wish to attend a gymnasium and he is now supported by staff to attend one in Thornton Heath on a regular basis. Another resident told the Inspector how he loves gardening and how he has been supported to grow vegetables in the home’s back garden. So it seems to be that service users are supported and enabled to take part in appropriate activities and that they are able to express their wishes and be listened to and responded to with active and appropriate support. Standard 13 – The service at Jordan Lodge actively encourages residents to develop and maintain social, emotional and independent living skills where ever possible. Staff at Jordan Lodge were seen by the Inspector to be actively supporting residents to make informed choices about the things they want to do and the activities they need to do. The central location of the home in Croydon makes access relatively easy for those residents who are able and want to use public transport. Residents interviewed by the Inspector confirmed this. The Manager informed the Inspector that all residents are registered to vote and are encouraged to use their votes. Residents confirmed with the Inspector that they are supported and enabled to vote. Jordan Lodge DS0000025803.V350903.R01.S.doc Version 5.2 Page 15 The Manager told the Inspector that relations with the local neighbours are good with no problems arising up to this point in time for the home or for the neighbours. Residents do seem to be engaged as much as is possible with their local community and that this will be likely to expand as their skills and abilities increase. Standard 15 – Interviews with 4 of the residents confirmed that where possible they do maintain regular contact with members of their families and either go out to visit their relatives or receive them at Jordan Lodge. Residents told the Inspector that they are enjoying the opportunities that they experience at this home. 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 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 user’s rights to privacy, respect and dignity are respected. 4 residents who were interviewed also confirmed that they felt staff respected these rights. Residents said that they have a key to their own bedrooms, that staff use their preferred form of address and that staff do knock on their doors before entering. The Inspector observed staff to be interacting with residents in a friendly and respectful manner and staff confirmed in interview that they understand how to respect the privacy and dignity needs of the residents. The Manager explained to the Inspector that all incoming and outgoing mail is logged into a record book and where residents need some assistance in opening and reading their mail, the resident is always asked first if they do want this assistance on that occasion. The Manager showed the Inspector the logbook and regular and up to date entries were seen up to the date of the inspection. Residents also confirmed to the Inspector the practice explained by the Manager. Following recent legislation on smoking, smokers now have to use a covered area outside the house and there are appropriate policies regarding drug and alcohol taking on the premises. Jordan Lodge DS0000025803.V350903.R01.S.doc Version 5.2 Page 16 Standard 17 – As a part of the inspection the Inspector inspected the kitchen that was in good order. The Manager explained that the home had recently and last week been inspected by the Environmental Health Officer. Only one recommendation had been made and this has subsequently been met. It required a check to be carried out for each meal’s food temperatures and a record to be kept. The new record book was seen by the Inspector to be in place. Food menus shown to the Inspector indicate that menus are well balanced, nutritional and cater for the varying cultural and dietary needs of the residents. Menu choices are provided and the Manager told the Inspector that some residents assist in the drafting of the food menus. A 4-week rolling programme is used within the home. However at interview several residents said that whilst they do enjoy the food at Jordan Lodge they would really appreciate more “home cooking”, for instance one resident said “home baked pies are a lot nicer than shop bought ones”. Another resident felt that the food supplied does not meet their cultural needs and would appreciate some increased diversity in the range of food provided to the residents. Again the issue of the supply of fresh fruit was raised. It is recommended therefore that the Manager increases the level of “home cooking”, looks at how the menu can be expanded to include some dishes to meet the cultural needs of the residents and also to extend the supply of fresh fruit. 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. Food monitoring records are kept for some residents where this is required on their care plans and this is linked in with weight and dietary monitoring so as to ensure care plan requirements are being met. 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. Jordan Lodge DS0000025803.V350903.R01.S.doc Version 5.2 Page 17 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19, & 20 were inspected at this inspection. Quality in this outcome area is excellent. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Service users may be assured that they will receive personal support in the way they prefer and require, they may also be assured that their physical and healthcare needs will be appropriately met. Service users are protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: Standard 18 – Residents who were interviewed at this inspection confirmed with the Inspector that they receive their care in the way they prefer. They said that they are able to decide themselves about their daily routines and this was backed up by care staff who were also interviewed by the Inspector. Staff ensure that care support at Jordan Lodge is person led, flexible, consistent and is able to meet the changing needs of the residents. Jordan Lodge DS0000025803.V350903.R01.S.doc Version 5.2 Page 18 It was confirmed by the staff and the residents that they are able to choose when they get up, when they go to bed, when they have a bath, what they wear and what they will do during the day. Standard 19 - The Manager told the Inspector 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. Information in their case files also evidences it by the recording of their contact with these services. It was confirmed that annual healthcare checks are routinely carried out by GPs. 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 (MAR sheets) and these were seen to be appropriately completed and in line with the home’s policies and procedures. Photographs of the residents were attached to the MAR sheets, which helps to ensure that staff administer medications to the right resident. It is recommended that guidance be provided about PRN medications that are used for residents stating when PRN medication should be used and the potential side effects for the individual resident. The resident’s GPs should be involved in this process and the information placed together with a medication profile for each resident. The Inspector did a spot audit check on the stock control system and this proved satisfactory with the levels of medications being as stated on the control sheets. A check on the storage facilities for the medication was seen to be appropriate. Controlled drugs are not currently in use within the home however due to a recent change in legislation appropriate provision will need to be made for controlled drugs i.e. that there is a lockable metal cupboard within a locked metal cabinet. Training in medication for staff is a part of the agencies training plan and the 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.V350903.R01.S.doc Version 5.2 Page 19 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 & 23 were inspected at this inspection. Quality in this outcome area is excellent. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Service users may be assured that their views will be listened to and that they will be protected from abuse, neglect and self-harm. EVIDENCE: Standard 22 – The 4 residents who spoke to the Inspector all individually confirmed that they feel their views are listened to and acted upon. They 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 homes’ complaints policy was inspected and found to be correct. The Inspector asked the Manager to see the home’s complaints record. No complaints had been registered in the record book since the last inspection and the Manager told the Inspector this because no complaints had been made. A complaints notice was seen by the Inspector on the home’s central notice board for all to see and read as required. The Manager also told the Inspector that a monthly monitoring report that details any complaints and the actions taken in response to them is now being Jordan Lodge DS0000025803.V350903.R01.S.doc Version 5.2 Page 20 sent to the Proprietors as part of the home’s quality assurance system. The outcome of this practice is that the home learns from complaints in order to improve its service and all the residents know that their complaints and concerns will be listened to and dealt with appropriately. Standard 23 – The home has an adult protection policy that is aligned to that of the local authority. The Manager informed the Inspector that all staff except the most recently joined members have had access to London Borough of Croydon’s training for the Protection of Vulnerable Adults (POVA). However recently the Manager said he had been informed that this was no longer going to be possible since LBC could no longer provide this training. The Manager explained that he and the Proprietors are therefore looking for alternative training sources for POVA and are actively considering an “on line” training course. The Inspector said that the effectiveness of this would of course depend on the course content and training methods. At the last inspection a recommendation was made that all staff undertake POVA training at least once every two years from an authorised trainer. The Manager informed the Inspector that this is understood to be best practice and that all but the most recently joined members of staff have now received POVA training. He said arrangements are being made for the remaining staff to receive this training very soon. Staff interviewed by the Inspector confirmed that they had attended this training. This means that staff are better aware of what abuse is and the safeguards in place for the protection of the residents should they need them. Access to external agencies is actively promoted by the staff at Jordan Lodge. The Inspector saw the allegation of abuse record; no allegations had been made since the last inspection. The Manager confirmed this to the Inspector. The policies and procedures manual for the home include 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 of this was seen on file, staff are asked to sign to say that they have read and understood the policies and procedures for the home. The Manager obviously takes the issue seriously and explained to the Inspector how staff have an opportunity to discuss anything not understood with their supervisor in their 1:1 supervision sessions. Jordan Lodge DS0000025803.V350903.R01.S.doc Version 5.2 Page 21 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 & 30. Quality in this outcome area is excellent. 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: Standard 24 – A tour of the home together with the Manager was undertaken as a part of the inspection and the home was seen to be clean and tidy in all areas. The general condition of the home and the facilities is good; communal areas and bedrooms are kept clean and odour-free. The staff provide a ‘homely’ touch through supplementary decoration and ornaments / flower decorations and pictures hanging on all the walls. The Manager and staff have ensured that the physical environment of the home provides for the individual requirements of the residents. Also the Jordan Lodge DS0000025803.V350903.R01.S.doc Version 5.2 Page 22 communal living areas were found to be appropriate by the Inspector for the needs of the residents at the time of the inspection. Four of the residents who spoke to the Inspector over the course of this inspection said that they see Jordan Lodge as their home and that they find it a nice place and are happy living there. The home is designed to provide small group living and people who live here can enjoy independence in a noninstitutional environment. There is space within the home that may be used to entertain guests or for residents to sit quietly in. Records were also shown to the Inspector by the Manager for other safety checks that have been carried out over the last year and that are part of a regular process of checks carried out to help ensure the safety of the residents. This includes weekly hot water checks of all the hot water outlets and checks of the temperatures of the home’s fridge and freezers. A handyman is employed to carry out routine maintenance around the home and a programme of repairs schedules what needs to be done and the priority level. Standard 30 – The Manager showed the Inspector the home’s infection control procedure, which seems comprehensive and to be effective in practice. At the time of this inspection the home was clean and hygienic. Staff interviewed confirmed that they are issued with appropriate clothing and equipment for them to carry out their work appropriately The laundry facilities in the home are appropriate for the residents who are living in the home. The Inspector was informed by the Manager that laundry is not taken through any areas where food is being prepared. Jordan Lodge DS0000025803.V350903.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 34 & 35. Quality in this outcome area is excellent. 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 – As part of the inspection the Inspector reviewed 4 of the 11 staffing files for Jordan Lodge and interviewed 4 members of the care staff as well as 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 saw evidence of this on staff files and also from discussions with staff interviewed. Staff have copies of the General Social Care Standards / Code of Conduct. Volunteers are not used within the home. Jordan Lodge DS0000025803.V350903.R01.S.doc Version 5.2 Page 24 The Inspector saw care staff working at Jordan Lodge to be approachable for the residents and to be taking time to deal with their questions appropriately and patiently. The Manager told the Inspector that the training programme for staff is good and covers all the essential training required by the staff to do their jobs well and efficiently. The provision of funding for training is also said to be good and the Manager told the Inspector that usually if a training need is identified then a training course is provided. The Manager informed the Inspector that all the care staff have either now achieved their NVQ level 2 awards or are on a training course to achieve the award. The Manager and the Deputy Manager have both gained their NVQ level 4 awards. The Inspector gained the impression over the course of this inspection that all the staff are committed to ensuring that their skills and knowledge is continually being developed by appropriate levels of training so that they can best meet the needs of the residents. Training records were examined by the Inspector and evidence was seen that evidenced staff having completing the following training courses: • 1st aid • Fire safety • Food safety • POVA • Aggression Management • Safe handling of medications • Infection control • Equal opportunities The Inspector discussed with the Manager and the staff group the need for more specific training in different areas of mental health and the Manager said that these needs have been identified and included together and overall with the staff’s training needs list. Aggregated via the supervision process the list provided shows what training courses are available for staff over the year 2007 – 2008. This training includes the following areas: • Fire training • First Aid • Aggression management • Mental Capacity Act • Care planning • POVA • Food records • Medication • Schizophrenia and bipolar disorders • Confidentiality and disclosure • Risk taking • Equal opportunities Jordan Lodge DS0000025803.V350903.R01.S.doc Version 5.2 Page 25 • • • • Service users group activities Legislation Managers on call Interpersonal skills. This represents a very positive support to staff and should equally benefit residents in that they will have a competent and skilled staff team who are better able to meet their needs. Standard 34 - The acting Manager told the Inspector that the home does have a recruitment policy and procedure and that all staffing posts are filled by application and interview. Evidence of these processes being used was seen by the Inspector on the staffing files. The Manager said that he, the Proprietor and another of the Group’s Homes Managers constitute the interview panel. Review of 4 of the staffing 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 (under Standard 34) to be gathered for staff was seen to be held on the staff files reviewed. The result of this is that there is at Jordan Lodge a staff team that has a balance of the skills, knowledge and experience to meet the needs of the residents. 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 – As already indicated earlier in this report the Manager has said that there is an overall training and development plan and budget for the home. 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 in interview with staff. It includes: • Safe working practices • The workers role • Meeting the needs of service users • The home’s policies and procedures. Training certificates were seen by the Inspector confirming that staff had attended the stated courses. The Manager also showed the Inspector a training matrix that identifies what training the staff team have as a whole. This is a very useful tool as it quickly illustrates where the gaps are in the overall teams training. Jordan Lodge DS0000025803.V350903.R01.S.doc Version 5.2 Page 26 It was equally good to be told by the Manager that the staffs training needs had been identified through the supervision process and aggregated into a training needs list. Together with the training matrix it should be very helpful as it may be used by the management team to plan all future training courses in the year ahead. This serves a dual purpose in that it easily informs the Manager what training the staff team have received and where the gaps in training exist. Standard 36 – The Manager told the Inspector that there is a properly structured staff supervision policy and procedure. Records were inspected and both the policy and the supervision tools comprehensively cover the areas that are required in order to implement an effective supervision process. Inspection of the supervision records that are held on staffing files showed that staff have received regular and formal supervision. Areas of discussion included: • Resident’s issues • The key working process • Monthly reports on progress made by key workers with care plans • Daily activities and outings for residents • Employment and training needs • Holidays and leave • Work performance issues. This means that all the key and important areas for the review and monitoring of the work being done in the home to meet the needs of both the residents and the staff groups should now be properly met. A previous requirement made at the last inspection that staff receive regular supervision using the policy and procedures already in place has now been met. The Manager informed the Inspector that annual appraisals have been carried out for staff in the unit and evidence of this was seen in the staff files. 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.V350903.R01.S.doc Version 5.2 Page 27 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39 & 42. Quality in this outcome area is excellent. 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: Standard 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 Jordan Lodge DS0000025803.V350903.R01.S.doc Version 5.2 Page 28 NVQ level 4 award. 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 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 Manager explained to the Inspector the quality assurance processes now being used within the home to ensure that resident’s views underpin all self-monitoring review and development by the home. The Manager said that following recommendations made at the last inspection the quality assurance process now includes a service user questionnaire that is used to gain feedback from the residents and other questionnaires have also been devised to get feedback on issues to do with quality, from friends, families and visiting professionals. Quality checks are made on the recruitment procedures used to employ staff and a room-by-room risk assessment of the building is completed annually, information from which also informs the developments to be made in the home and all of which informs a development plan for Jordan Lodge. The development plan is discussed with the Proprietors so as to ensure priorities outlined in the report are met. The previously made requirement has now therefore been met and with the implementation of this new quality assurance tool it should mean that there is in place a very effective method of maintaining high quality standards in the home. Standard 42 – The Inspector was shown information 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 receive training in fire safety, first aid, food hygiene, and infection control. This was supported by staff interviewed that confirmed that they had received training in these areas. Up to date and satisfactory certificates were seen by the Inspector for: Boiler – 2.5.07 Gas – 3.9.07 Fire alarms – 22.10.07 Fire extinguishers – 11.5.07 Water / legionnaires tests – 17.10.07 All food was seen to be stored appropriately and properly labelled with dates of opening and expiry. Jordan Lodge DS0000025803.V350903.R01.S.doc Version 5.2 Page 29 Records were seen by the Inspector that confirmed regular tests had been carried out for the: Fire alarm – weekly and records seen up to 4.11.07 Fire extinguishers - monthly Emergency lighting – 6 monthly last on 21.10.07 Fridge and freezer temperatures records were checked and records indicate that they came within the acceptable ranges. Accident records were checked – nothing had been recorded and the Manager confirmed none had arisen since the last inspection. Hot water temperatures were also checked and records indicated that they also came within the acceptable range. At the time of this inspection no fire doors were seen to be wedged open and the building appeared to be secure. The Manager showed the Inspector a recently completed risk assessment for the building and for the communal areas. This is welcomed as it should assist in the prevention of accidents and will inform the maintenance programme for the building. Jordan Lodge DS0000025803.V350903.R01.S.doc Version 5.2 Page 30 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 4 3 X 4 X 5 4 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 4 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 4 33 X 34 4 35 4 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 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 4 X 4 X 4 X X Jordan Lodge DS0000025803.V350903.R01.S.doc Version 5.2 Page 31 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. 1. Refer to Standard YA17 Good Practice Recommendations That the Manager increases the level of “home cooking”, looks at how the menu can be expanded to include some dishes to meet the cultural needs of the residents and also to extend the supply of fresh fruit. That guidance be provided about PRN medications that are used for residents stating when PRN medication should be used and the potential side effects for the individual resident. The resident’s GPs should be involved in this process and the information placed together with a medication profile for each resident. 2. YA20 Jordan Lodge DS0000025803.V350903.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Jordan Lodge DS0000025803.V350903.R01.S.doc Version 5.2 Page 33 - 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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