Inspection on 24/04/06 for Lammas Lodge

This inspection was carried out on 24th April 2006.

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

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

Other inspections for this house

Lammas Lodge 25/09/08

Lammas Lodge 25/09/07

Lammas Lodge 01/12/05

Lammas Lodge 07/06/05

Lammas Lodge 20/03/05

Lammas Lodge 14/10/03

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Lammas Lodge Lugwardine Hereford Herefordshire HR1 4DS Lead Inspector Jean Littler Unannounced Inspection 24th April 2006 04:20 Lammas Lodge DS0000024739.V288133.R02.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Lammas Lodge DS0000024739.V288133.R02.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Lammas Lodge DS0000024739.V288133.R02.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Lammas Lodge Address Lugwardine Hereford Herefordshire HR1 4DS 01432 853185 01432 851468 lammas.lodge@craegmoor.co.uk 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) Parkcare Homes Limited Mrs Rosemary Elizabeth Wooderson Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Lammas Lodge DS0000024739.V288133.R02.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. In addition to Learning Disability, Service Users will have needs associated with autism spectrum disorder. For each assessment indicating the need for professional services, a statement is provided to the funding authority, in advance of the admission, showing the agreed contractual arrangements for its delivery. A copy of the statement must be retained at the home and be available for inspection by the Commission. A designated senior in charge of the service, who is suitably trained and experienced, must be on duty at all times. All staff must receive training in autism spectrum disorder and appropriate behaviour management techniques within 12 weeks of starting work at the home. The Care Manager must be provided with formal recorded one to one supervision sessions with a Line Manager every month for the first 12 months of her registration in respect of the service provided at Lammas Lodge. Service users abilities to manipulate bedroom door locks must be assessed at the point of admission. A written record of this assessment must be included in the care plan with details of action taken for any service users who are unable to manage the existing style of fitted lock. 1st December 2005 3. 4. 5. 6. Date of last inspection Brief Description of the Service: Lammas Lodge offers 6 places to younger adults of either sex who are between the ages of 18 and 65 years at the point of admission. Personal care needs arise from a learning disability and will include needs associated with Autism Spectrum Disorder. The Statement of Purpose describes a therapeutic atmosphere and a full social/recreational and educational programme will be identified prior to admission. The providers state that a high staffing ratio will be provided to meet the assessed support and supervision needs of residents with complex needs. The Home is situated on the outskirts of Lugwardine village, which is three miles from Hereford. The house is set in large grounds with an area for activities and a sensory garden. The house is large and is divided into three areas. There is a self-contained one bedroom flat, the main house that provides one ground floor and four first floor en-suite bedrooms, and a staff office and meeting area. Two unmarked vehicles are provided to facilitate community access. Lammas Lodge DS0000024739.V288133.R02.S.doc Version 5.1 Page 5 The providers have written information about the service that can be sent out to interested parties. The most recent inspection report is on display in the visitors’ area of the Home. The current fee range is between £1600 and £2530 per week dependent on each individual’s assessed needs. Additional charges are made for personal items such as clothes and toiletries, personal services such as chiropody, haircuts and holidays, although the providers contribute £200 towards the cost of holidays and fund the staffing costs. Lammas Lodge DS0000024739.V288133.R02.S.doc Version 5.1 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This routine inspection was carried out over two days to assess the service against the Key National Minimum Standards. The first visit to the Home was an unannounced inspection on 24th April between 4.20-5.10pm and this was followed by an announced inspection on 2nd May between 10am and 5.30pm. The manager completed a pre-inspection questionnaire to provide additional information, which was received by the Commission on 13th April. The residents, their representatives and some professionals involved were given feedback questionnaires, some of which were returned. One resident’s family expressed positive comments about the service ‘The Home provides a warm and welcoming home for our son, and the staff we have come into contact with are concerned with his safety and wellbeing’. The providers monthly visit reports to the Commission, and other communication with the Home since the last inspection were all considered as part of the process. The inspector toured the building, spoke briefly to one resident and observed two others while they were interacting with staff and following their early evening routine. The deputy assisted with the inspection process on the unannounced visit and the manager was present to assist during the announced visit. A support worker and team leader were interviewed and the afternoon handover between two team leaders was observed. Records were reviewed and two residents’ files and care arrangements were closely examined. What the service does well: What has improved since the last inspection? The way the home is being managed has improved now the manager has a deputy and four senior staff to help her. Less staff from agencies are being used now and the care staff are now working when they are most needed to help residents go out. A second vehicle has been provided to ensure all outings can take place. Staff have attended training in new areas and more of them Lammas Lodge DS0000024739.V288133.R02.S.doc Version 5.1 Page 7 are working towards getting a qualification in Care. A system to check if the home and the quality to life of the residents can be improved has been set up. 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. Lammas Lodge DS0000024739.V288133.R02.S.doc Version 5.1 Page 8 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 Lammas Lodge DS0000024739.V288133.R02.S.doc Version 5.1 Page 9 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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Information about the service is given to residents’ representatives and other interested parties. Ways of informing people with Autism Spectrum Disorder about the service, in a meaningful way, are still being developed. Suitable arrangements are now in place to assess the needs of potential new residents. EVIDENCE: The providers have recently taken the decision to change the Statement of Purpose for the Home. The Home was originally set up with the intention of providing a transitional service for people between 18 and 25 years who would develop their life skills and then move on to more independent living. There are currently two vacancies in the Home and the providers have judged that the age range for admission needs to be more flexible to fill these so the upper limit has been removed. The families of current residents have been informed of this change. A copy of the revised Statement of Purpose needs to be provided to the Commission in line with Regulation 4. A Service User’s Guide is in place. This and the Statement of Purpose have been made available to those interested in accessing the service. Copies of the Guide were not found on either of the residents’ files that were sampled but the manager confirmed that they had been given out and that one resident’s family currently had their son’s copy. The manager should keep evidence of Lammas Lodge DS0000024739.V288133.R02.S.doc Version 5.1 Page 10 how any future residents are provided with information about the Home in a way that is meaningful to them. A new corporate assessment tool has recently been produced. The manager is aware of the need to carry out a thorough assessment prior to a trial period being offered to any new resident. She plans to involve the specialist clinical team in reviewing any future referrals so joint decisions are made. No new residents have been admitted since the last inspection and one resident has left. The manager is aware that a formal agreement about funding, to meet a potential resident’s current and anticipated health care, need to be in place prior to their admission. Lammas Lodge DS0000024739.V288133.R02.S.doc Version 5.1 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Effective care planning and reviewing systems are in place to ensure staff are aware of the residents’ complex care needs. The residents are being assisted to make decisions about their lives and take reasonable risks on a daily basis. EVIDENCE: The personal records of two residents were sampled and case tracked. These showed that their needs had been fully assessed and detailed guidance and risk assessments put in place to inform staff about how their needs should be consistently met. The records seen included reports on daily activities, health issues, behaviour patterns, work towards personal goals, accidents, incidents and complaints. Monthly summary reports were being collated from the useful information in the daily records. Review meetings had been held recently with the residents’ representatives. All four residents have individual activity plans in place that include pastimes like swimming, running club, badminton. Because trips into the community for activities pose some risks but also provide real benefits for the residents Lammas Lodge DS0000024739.V288133.R02.S.doc Version 5.1 Page 12 measures have been put in place to help trips to be successful e.g. two staff support one resident, the ‘social story’ technique is used before each trip. Some residents do need to be physically restrained if they become distressed and aggressive to staff, or put themselves at risk while out in the community. Clear behaviour intervention plans are in place that have been developed with the behavioural therapist. The residents’ representatives are aware of the arrangements in place and are told when incidents occur that require restraint techniques to be used. Clear records are kept of each incident and these are copied to the Commission. Staff involved are debriefed afterwards. The level and frequency of use of restraint seem appropriate for the circumstances of each incident. The overall risk to residents and staff needs to continue to be kept under close scrutiny and reviewed against the suitability of the placements. All residents are being supported to make decisions at a level that they can cope with e.g. what meal do they want, do they want to go on their next planned outing. The manager is aware of the current developments in Person Centred Planning but is waiting for the new corporate approach to this to be introduced. The launch of this new development has been delayed by several months but the training is now due to be held in June 06. Lammas Lodge DS0000024739.V288133.R02.S.doc Version 5.1 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): 11, 12, 13, 14, 15, 16, 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Positive arrangements are in place to provide residents with active and enjoyable experiences each day that they have some choice and control over. They are being encouraged to develop their life skills and self-confidence. Good efforts are being made to maintain links with families and to support the residents to mix in the community. Mealtime arrangements offer choice whilst encouraging a healthy diet. EVIDENCE: All four residents have very different activity plans that have been developed based around their assessed needs and interests. The rotas are now being planned specifically around the activity plans and each resident goes out at least once, and often twice a day. All residents are being supported to access the community regularly e.g. for shopping, college or sports sessions. Some activities are non-segregated to give the residents the opportunity to mix regularly with local people. Some outings are also for leisure such as pub visits although quiet times of the day are chosen. In-house, the activities area is used for art and games and staff reported that the gym is also used. The Lammas Lodge DS0000024739.V288133.R02.S.doc Version 5.1 Page 14 grounds are used for games and there are plans to grow more vegetables this year. The residents are made aware of the next planned activity and given the opportunity to say if they want to take part. A structure is an important part of each resident’s daily routine but a flexible approach is also taken so individual’s wishes and frame of mind can be taken into account. A second vehicle was provided in December 05 to allow two outings to take place simultaneously. Existing hobbies and interests continue to be supported e.g. video collecting and watching. The residents are being encouraged to develop independence skills such as cleaning their own rooms and doing some cooking. The Speech and Language Therapist is involved regularly and supports the development of communication aides that help the residents develop their communication, social and life skills. Because of their condition the residents have not developed friendships with each other, however the group seems relatively compatible within the highly individualised service. The staff are guided by a Behavioural Therapist about how to support residents to develop social skills and how to respond to them expressing their sexuality. All residents are being supported to stay in regular contact and visit their families. Relatives have been involved in supporting the residents to personalise their bedrooms and reviews are being held regularly to provide opportunities for relatives to be part of reviewing and planning the care being provided. Food is purchased locally every few days with the residents’ involvement. The menus were seen and these confirmed staffs reports that a healthy diet is encouraged. The manager is considering how to access nutritional advice as one resident has quite limited types of food he likes. Lammas Lodge DS0000024739.V288133.R02.S.doc Version 5.1 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents’ personal and health care needs are being met in a flexible and personalised manner. Medication is being safely managed and administered by suitably trained staff. EVIDENCE: A ratio of at least one to one staffing is provided during the waking hours. This allows the residents to be supported with their personal and health care needs in a very personalised manner at a speed that suits them. Routines are being kept as flexible as possible e.g. residents can have a lie in unless they are due to go out e.g. to college. Arrangements are in place to meet each resident’s current health needs e.g. chiropody, GP, annual dental checks. There have been difficulties accessing some health care services due to the residents funded from other counties, but the problems to date have been resolved. The organisation provides input from a team of specialists including a psychiatrist, behavioural therapist and a speech and language therapist who provide monthly clinical surgeries. The manager agreed to explore with the GP if they could be supported to set up Health Action Plans in line with the Governments Valuing People Policy. Lammas Lodge DS0000024739.V288133.R02.S.doc Version 5.1 Page 16 Currently annual Wellman’s health checks have not been set up as described in the standards. Clear records of health issues are being kept. A ‘grab’ sheet of basic information is in place to take to hospital in the event of an emergency. The medication is stored in an appropriate cabinet with the additional security of this being inside a locked treatment room. The keys are held by senior staff who are appropriately trained. Arrangements have been improved as records are now kept to show that staff do not administer medication until they have been formally judged by the deputy to be fully competent and understand the Home’s medication procedure. Two staff are involved in administration to try to reduce the risk of any errors. The administration and returns records were in order and contained the relevant details. One document, held with the charts, to guide staff about when to administer ‘as needed’ medication needs to be reviewed, as it did not contain the necessary information. The deputy agreed to do this immediately. The prescribing doctors are reviewing medication regularly. Lammas Lodge DS0000024739.V288133.R02.S.doc Version 5.1 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Suitable arrangements are in place to enable complaints and respond to them. A framework is in place to help protect the residents from abuse. EVIDENCE: A complaints procedure is in place and the manager had logged four complaints received in the last year. Details of how the complaints were responded to were noted on corporate forms. A very recent complaint had not been entered yet, but the manager informed the inspector about this and shared the details and proposed meeting date to address the concerns. An entry about this was added to the complaints folder during the inspection. The staff spoken with were clear they would report any concerns promptly and felt the standards of care and staff conduct in the Home were high. Staff training is provided in Adult Protection and clear guidance is in place about how to respond positively to residents’ complex behaviours. An Abuse and Whistle Blowing policy are in place and on display. Protection is also being covered in the induction and during supervision sessions. The manager has made one Vulnerable Adult referral since the last inspection. This was a very unusual situation and not one that implicated anyone employed in the Home. The manager worked positively with the multi-agency team to share information appropriately and protect the resident until he left the Home. Lammas Lodge DS0000024739.V288133.R02.S.doc Version 5.1 Page 18 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, 25, 26, 27, 28, 30. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The Home provides a spacious and low arousal environment for the residents that is comfortable and well maintained. Their bedrooms provide private facilities and have been personalised to suit their preferences. Appropriate arrangements are in place to ensure the Home is clean and hygienic. EVIDENCE: The Home was refurbished in 2004 and is still in good condition throughout. A full time handy-person is employed to manage the grounds and deal with repair, redecoration and maintenance needs. The five bedrooms are a reasonable size and have en-suite facilities. The communal areas are spacious and include a large and small lounge, dining area, kitchen, gym, relaxation/activities room, large grounds and a sensory garden. An area at the rear of the house has been made into a self-contained flat for one resident with its own entrance. There are staff facilities and an office and meeting area. The bedrooms seen were personalised and homely. Some have been fitted with personal equipment such as televisions. The layout and decoration reflect the need to keep residents’ level of stress and stimulation to a minimum. Where Lammas Lodge DS0000024739.V288133.R02.S.doc Version 5.1 Page 19 residents cannot manage the bedroom door locks staff ensure the rooms are locked when the resident is out of the Home. The Home was clean and tidy at the time of both visits. The laundry was well organised and all equipment was working. The door is kept locked when the room is not in use. Residents are supported to use the laundry to develop their skills. The cleaner has left since the last inspection and has not yet been replaced. Staff are carrying out the cleaning routines. While there are only four residents this seems to be a reasonable arrangement, however it should be reviewed when the Home is fully occupied. The manager confirmed that the food management hazard analysis work, required following the Environmental Health inspection in February 2005 has now been completed. Cleaning schedules are now in place as a result of this work. Lammas Lodge DS0000024739.V288133.R02.S.doc Version 5.1 Page 20 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, 33, 34, 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Suitable recruitment arrangements are in place to help protect residents. The residents are benefiting from sufficient staffing levels. A training programme is in place but some staff have not been provided with essential autism training as promptly as they should have been and only a quarter of the team hold a relevant qualification. EVIDENCE: Systems are in place to monitor individual staffs training needs and to provide an overview of what training needs to be provided for the team. Core training e.g. health and safety, is being provided through in-house workbooks. The corporate induction includes the Learning Disability Award Framework units (LDAF), and specialist training is also being provided e.g. sexuality and people with ASD. Currently only 24 of the care staff hold an NVQ in Care. This is below the minimum standard of 50 , however seven staff are currently working towards gaining Awards so this target should be achieved in the next year. The manager felt that all training needs of the team are now being provided for except the training staff need before they can be approved to use physical restraint when needed. The local authority has been providing this but there has not been any courses for several months. Because this is making staffing arrangements in the home difficult the providers should consider providing this through another source. The staff spoken with felt the training Lammas Lodge DS0000024739.V288133.R02.S.doc Version 5.1 Page 21 they have received has been appropriate and beneficial to them in the roles. The staff on duty were seen to interact with residents in a sensitive and appropriate manner. A condition of the Home’s registration is that staff must be provided with Autism training during the first twelve weeks of their employment. This target had not been achieved for seven staff. The manager was aware that the condition had been breached, which is an offence under the Care Standards Act 2000, but she had not notified the Commission. The deputy has now been trained to present training on Autism Awareness and dates have been set for all staff who need to attend. As appropriate arrangements have been put in place, the Commission will take no further action on this occasion. The manager needs to inform the Commission promptly if this situation arises again. Despite the delay in providing this training staff had been provided with written information about Autism and made aware of each resident’s individual needs. Staff rotas showed that an appropriate level of staffing continues to be provided. Any gaps are covered by the staff working additional hours or by agency staff. Three new staff are due to start shortly and this would have meant the team was fully staffed, however one resident has recently been assessed as needing increased staffing support following incidents over the previous week. Staffing levels during the day and at night had been increased with immediate effect and the funding authority informed. Up until this point the use of agency staff had decreased considerably. A team leader and support worker were spoken with in private. They were positive about the residents and felt that they were being provided with a very personalised service and a good quality of life. They had a good understanding of the residents’ needs and how essential a consistent approach is. They confirmed that the staffing levels are appropriate, and reported that their regular supervisions with a line manager are supportive. When staff are involved in challenging and difficult incidents with residents debriefings are held with senior staff. Some staff have sustained violent physical and more recently sexual assaults from residents. The providers should give serious consideration to arranging for staff to have access to professional confidential counselling in these cases. Two staff files were sampled to check the recruitment process. These showed that the process is robust and clear records are being maintained. One of the two staff started work following receipt of a POVA 1st check but prior to the full CRB being returned. The manager was made aware that the POVA 1st checks are only to be used in exceptional circumstances and a record should be held on the file to provide evidence of what these circumstances were. Lammas Lodge DS0000024739.V288133.R02.S.doc Version 5.1 Page 22 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, 40, 41, 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Home is being well run by a competent manager who prioritises the residents’ wellbeing. Appropriate management and record keeping systems are in place. A wide range of corporate policies are in place but these have not been reviewed recently. A quality assurance system has recently been introduced. Residents Health and Safety is being promoted. EVIDENCE: The manager holds relevant qualifications and has many years experience of managing services for people with special needs. The staff reported that she is professional, approachable, well organised and very focused on residents’ needs. The management systems in place e.g. shift handovers, communication book, staff meetings and supervision sessions provided time for the residents’ complex needs and the staffs’ ability to respond to them to be kept under close review. The manager is better supported now one of the team leaders has been promoted to deputy and four team leaders are in post. Each member of Lammas Lodge DS0000024739.V288133.R02.S.doc Version 5.1 Page 23 the senior team has been on specific delegated areas of management responsibility. A provider’s representative has been carrying out monthly monitoring visits to the Home. The reports have not been provided to the Commission since January 2006 but an arrangement to provide copies electronically has now been made. These should always report on the challenging behaviour being managed in the Home and the level of risk being managed by the staff. The organisation has introduced a formal Quality Assurance system in January that comprises of a series of audits over a two-year period that should trigger any improvements needed. The first audit, Health and Safety, was completed in April. The effectiveness of this system will be assessed again at the next key inspection when it has been more fully implemented. The manager was made aware that each review period must include consultation with stakeholders and result in a report showing a cycle of improvement that is to be shared with the stakeholders and the Commission. The manager agreed to provide residents’ families with a copy of the inspection report summary following this suggestion being made by one family in their feedback questionnaire. Records are being stored in an office area that is secured when not in use. The sample of records seen were up to date, they contained useful and appropriate information that were accurate and well ordered. Many of the corporate polices and procedures have not been reviewed recently and most are dated 2004 or 2002. The manager reported that the corporate Clinical Governance Team are due to review the policy set. She agreed to clarify with this team why she could not locate some of the policies detailed in the Younger Adults National Minimum Standards. This may be to do with how they are indexed. Health and Safety (H&S) and maintenance checks were detailed in the preinspection questionnaire. This information was sampled during the inspection and records confirmed it to be accurate e.g. the date fire equipment was last serviced. The senior now leading on H&S is devising new recording systems that will help improve arrangements e.g. the new fire drill record will highlight which staff need to attend the next drill. Risk assessments are in place for environmental hazards and other potential risks e.g. kitchen knives are locked away and checked regularly. No unmanaged hazards were identified during the inspection. Lammas Lodge DS0000024739.V288133.R02.S.doc Version 5.1 Page 24 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 2 2 3 3 X 4 X 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 4 26 4 27 4 28 4 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 3 x LIFESTYLES Standard No Score 11 4 12 4 13 4 14 4 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 3 x 4 X 3 3 3 3 x Lammas Lodge DS0000024739.V288133.R02.S.doc Version 5.1 Page 25 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. 2. 3. 4. 5. 6. 7. Refer to Standard YA1 YA19 YA32 YA35 YA34 YA36 YA40 Good Practice Recommendations Provide evidence of how any future new residents are provided with information about the Home in a way that they can understand. Introduce Health Action Planning and annual Wellman’s health checks for the residents, in line with the Governments Valuing People Policy. Consider arranging physical intervention training from another source to ensure staff have the skills they need. See No.3 above. Ensure POVA 1st checks are only used in line with the Guidance issued by the Department of Health in July 2004. Provide staff with access to professional counselling services as part of the network in place to support them. The home’s written policies and procedures comply with current legislation and recognise professional standards, covering topics set out in Appendix 2 of the National Minimun Standards forAdults (18 –65). DS0000024739.V288133.R02.S.doc Version 5.1 Page 26 Lammas Lodge 7. YA42 The providers should closely monitor the level of aggression the staff have to manage and ensure they are not exposed to unacceptable risks. Lammas Lodge DS0000024739.V288133.R02.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Hereford Office 178 Widemarsh St Hereford Herefordshire HR4 9HN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Lammas Lodge DS0000024739.V288133.R02.S.doc Version 5.1 Page 28 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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