Inspection on 12/12/03 for Lodge Lane Nursing Home

Care Homes For Adults (18 ­ 65)Lodge Lane Mental Nursing Home10a Lodge Lane Bewsey Warrington Cheshire WA5 0AGUnannounced Inspection12th December 2003 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Lodge Lane Mental Nursing Home Address Lodge Lane Mental Nursing Home, 10a Lodge Lane, Bewsey, Warrington, Cheshire, WA5 0AG Email Address Tel No: 01925 418501 Fax No:Name of registered provider(s)/Company (if applicable) Warrington Community Care Name of registered manager (if applicable) Miss Jacqueline Harvey Type of registration Care Home No. of places registered (if applicable) 20Category(ies) of registration, with (number of places) Mental disorder, excluding learning disability or dementia (20) Registration number F010000194 Date First registered 22nd July 2002 Was the home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 22nd July 2002 Yes NO 7/3/03 If Yes Refer to Part CLodge Lane Mental Nursing HomePage 1 Date of Inspection Visit Time of Inspection Visit Name of Inspector Name of Inspector Name of Inspector 1 2 312th December 2003 09:30 am John MillsID Code078183Name of Inspector 4 Name of Lay Assessor (if applicable) Lay assessors are members of the public None present independent of the NCSC. They accompany inspectors on some inspections and bring a different perspective to the inspection process Name of Specialist (e.g. None Interpreter/Signer) (if applicable) Name of Establishment Representative at J. Harvey the time of inspectionLodge Lane Mental Nursing HomePage 2 CONTENTSIntroduction to Report and Inspection Inspection visits Description of service Part A: Summary of Inspection Findings Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods Used & Findings The Standards. National Minimum Standards for Care Homes for Adults (18 ­ 65) 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: Part E: E.1. E.2. E.3. Compliance with additional conditions of registration ( if applicable) Lay Assessors summary (where applicable) Providers Response Providers comments Action Plan Providers agreementLodge Lane Mental Nursing HomePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the National Care Standards Commission (NCSC) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 as amended. This document summarises the inspection findings of the NCSC in respect of Lodge Lane Mental Nursing Home. The inspection findings relate to the National Minimum Standards (NMS) for Care Home published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum standards will form the basis for judgements by the NCSC regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Report of the Lay Assessor (where relevant) · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000 and the Children Act 1989 as amended. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates.Lodge Lane Mental Nursing HomePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Lodge Lane is a service for adults with a history of long standing mental health needs. The service is provided within a modern two storey building on the outskirts of Warrington and in the local community of Bewsey. The home is situated close to local shops and is in close proximity to other community facilities and public transport. The service is provided by a voluntary organisation, Warrington Community Care and staff and service users benefit from the organisational support provided through local management.Lodge Lane Mental Nursing HomePage 5 PART ASUMMARY OF INSPECTION FINDINGSInspectors Summary (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) This unannounced inspection was carried out looking at a limited number of the National Minimum Standards, those standards not looked at during this inspection will be addressed in the next announced inspection. Readers of this report are advised to read this report in conjunction with the previous report. Conversations and interviews were carried out specifically with one member of the qualified nursing staff and with two service users. On the morning of the day of the inspection the manager of the home had left the home to undertake a pre-admission assessment of a potential service user. The manager did however return to the home at lunch time. The inspection process was therefore conducted with one of the qualified nurses, who was in charge of the home during the managers absence. Choice of home: Standards 1- 5 All of the standards in this area were assessed and found to be very well met and standard 3 was evidenced as exceeded. A Statement of Purpose and Service User Guide has been produced by the registered provider and has been made available to existing service users. There was evidence that all service users are assessed by qualified health & social care professionals prior to admission and have the opportunity to visit the service prior to any decision to move in is made. Individual Needs and Choices: Standards 6 ­ 10 At this inspection only standards 6 and 9 were assessed both were found to be well met and standard 6 was evidenced as exceeded. The processes used to identify service users needs were evidenced as being comprehensive in content and the subsequent development of care plans and goals were focused and specific to each individual. Lifestyle: Standards 11 ­ 17 At this inspection standards all of these standards, with the exception of standard 15 & 17 were assessed and found to be well met. There was evidence that the staff within the home respect each service user as an individual with their own experiences of life and personal preferences. There is an open and relaxed atmosphere within the service and each person is encouraged to maintain responsibility for as much of their own lives as possible. The location of this service within a local community promotes the accessing of local resources and facilities. Personal and Health Care Support: Standards 18 ­ 21 Lodge Lane Mental Nursing Home Page 6 Only standard 20 of these standards was assessed at this inspection, Assessment of this standard relating to the management of medication evidenced that the standard was being met. Examination of records relating to the receipt, storage and administration of medication confirmed that qualified nursing staff within this service were maintaining the required standard. Concerns, Complaints and Protection: Standards 22 ­ 23 Neither of these standards were assessed at this inspection. Environment: Standards 24 ­ 30 All of the standards within this section were assessed at this inspection and confirmation was made that these standards were being met. There are policies, procedures and systems in place that maintain the cleanliness and appearance of the home. The staff member spoken with understood her responsibilities within her own sphere of work. The general appearance of the home is of a well maintained and comfortable place to live. Each of the service users bedrooms had been decorated and personalised to reflect the individual character of the occupant. Staffing: Standards 31 ­ 37 During this inspection only standard 37 was assessed. This inspection confirmed that a system and process of staff supervision was in place. This identified that the staff team is supervised by the qualified nurses who n turn are supervised by the manager. This process provides for a minimum of six supervision session a year. The subjects covered were confirmed as including; work performance, relationships with service users and staff, training and personal development. Conduct and Management of the Home: Standards 37 ­ 43 At this inspection standards 37, 40 and 42 were assessed, with the exception of standard 42 all were found to be well met. With regard to Standard 42, there was no record to confirm that the gas heating system had been checked by a Corgi registered heating engineer since 2001. An immediate requirement was issued to address this shortfall. There is an experienced core team of staff being supported by a manager whose knowledge of the service users and their various experiences is positively directing this service.Lodge Lane Mental Nursing HomePage 7 Requirements from last Inspection visit fully actioned? If No please list belowYESSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. No. Regulation Standard Required actions Timescale for action None Action is being taken by the National Care Standards Commission to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations Standard None CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS). NoneMET (YES/NO)Lodge Lane Mental Nursing HomePage 8 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements and recommendations are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, the National Minimum Standards and the relevant sections of the Childrens Act. The Registered Provider(s) is/are required to comply within the given time scales. No. Regulation Standard * Requirement Timescale for action 1 23 YA42 The registered person must ensure that the gas heating system is checked by a Corgi registered engineer. ImmediateRECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s) No. Refer to Good Practice Recommendations Standard ** Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. YA10 refers to Standard 10.PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct Observation Indirect Observation Sampling · Pre-inspection Questionnaire YES YES NOLodge Lane Mental Nursing HomePage 9 · Records · Care Plans / Care Pathways · Meals · Activities · Other enter details here `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting Professionals survey / feedback Tour of Premises Formal Interviews Document reading Additional Inspection Information: Number of Service Users spoken to at time of inspection Number of Relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the Responsible Individual seen CRB check for the Manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total No. of care staff employed (excluding managers) Total No. of staff with nursing qualifications employed Date of Inspection Time of Inspection Duration Of Inspection (hrs)YES YES NO YES YES YES NO YES NO YES YES NO NO NO YES NO YES 3 0 0 NO NO YES NO 13 6 12/12/03 09.30 4.30The following pages summarise the key findings and evidence from this inspection, together with the NCSC assessment of the extent to which the National Minimum Standards have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No Shortfalls) (Minor Shortfalls) (Major Shortfalls) Page 10Lodge Lane Mental Nursing Home 0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Lodge Lane Mental Nursing HomePage 11 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · Prospective service users have the information they need to make an informed choice about where to live. Prospective service users individual aspirations and needs are assessed. Prospective service users know that the home they 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.Standard 1 (1.1 ­ 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives, philosophy of the home, its services and facilities and terms and conditions; and provides each service user with a service users guide to the home. The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the service users guide. X X Range of fees charged From To £ £ (per week) NO Any charges for extras If yes, please state what the extras are 3 Key findings/Evidence Standard met? Since the previous inspection a new Statement of Purpose has been produced by the manager of this service, a new Service User Guide has also been produced. Copies of These documents were provided to the inspector for examination and it was confirmed that these documents contained all the appropriate elements and information necessary to meet this standard. Copies of the Service User Guide had been provided to each existing service user, there were also copies of these and the most recent NCSC Inspection report available in the entrance foyer.Lodge Lane Mental Nursing HomePage 12 Standard 2 (2.1 ­ 2.8) New service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user using an appropriate communication method, and with an independent advocate as appropriate. 3 Key findings/Evidence Standard met? This standard was evidenced as being met both through examination of three identified service user case files but also by the fact that the manager was undertaking a preadmission assessment on the morning of the inspection. The assessments undertaken by the nursing staff from within the service are also supported by additional assessments taken by other care and heath professionals under the Care Programme Approach (CPA).Standard 3 (3.1 - 3.10) The registered person can demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 4 Key findings/Evidence Standard met? The design, layout and facilities of the service are suitable to the physical and social needs of this service user group. The experiences, qualifications and ongoing training of all staff ensures that service users are supported by a knowledgeable and competent staff team. There are also within this service appropriate equipment to support ant service users with reducing mobility or increasing facility, these include adapted bathing, pressure relieving mattresses, Kings Fund beds and hoists to facilitate safe moving and handling. These are further supported by a range of paperwork that facilitate the clear identification of individual needs and the prescribing of focused goals and care plans.Standard 4 (4.1 - 4.5) The registered manager invites prospective service users to visit the home on an introductory basis, before making a decision to move there, and unplanned admissions are avoided wherever possible. 3 Key findings/Evidence Standard met? Confirmation was made through conversations and examination of records that this opportunity is an underlying principle and practice within this service. Where it has been deemed impractical for such visits to take place, family members are invited to view the service on behalf of potential service users.Lodge Lane Mental Nursing HomePage 13 Standard 5 (5.1 - 5.5) The registered manager develops and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user. 3 Key findings/Evidence Standard met? Those case files examined contained Licence Agreements, which specified the information required within this standard.Lodge Lane Mental Nursing HomePage 14 Individual Needs and ChoicesThe intended outcomes for the following set of standards are: · · · · · 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.Standard 6 (6.1 ­ 6.10) The registered manager develops and agrees with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home and how these services will meet current and changing needs and aspirations and achieve goals. 4 Key findings/Evidence Standard met? Using the process of case tracking, the case files and care plans of three identified service users were examined, These were confirmed as not only containing all the elements required by this standard and regulation by had a range of assessment formats that address, emotional, social and personal care needs. The presentation of this information was of such a standard that the manager is to be commended on the processes developed.Standard 7 (7.1 ­ 7.7) Staff respect service users right to make decisions and that right is limited only through the assessment process, involving the service user and as recorded in the individual Service User Plan. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection but will be assessed at the next.Lodge Lane Mental Nursing HomePage 15 Standard 8 (8.1 ­ 8.5) The registered manager ensures that service users are offered opportunities to participate in the day-to-day running of the home and to contribute to the development and review of policies, procedures and services. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection but will be assessed at the next.Standard 9 (9.1 ­ 9.4) Staff enable service users to take responsible risks, ensuring they have good information on which to base decisions within the context of the service users individual Plan and of the homes risk assessment and risk management strategies. 3 Key findings/Evidence Standard met? Examination of care plans evidence that comprehensive risk assessments had taken place, confirmation was given by the nurse in charge that whilst all service users are subject to risk assessments the philosophy within the service was to support each person in developing a level of independence and autonomy within their own capabilities. This was confirmed through the social activities undertaken by several service users and the access of open employment enjoyed by other service users during the week.Standard 10 (10.1 ­ 10.6). Staff respect information given by service users in confidence and handle information about service users in accordance with the homes written policies and procedures and the Data Protection Act 1998 and in the best interests of the service user. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection but will be assessed at the next.Lodge Lane Mental Nursing HomePage 16 LifestyleThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 11 (11.1 ­ 11.4) Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 3 Key findings/Evidence Standard met? This inspection confirmed that service users where able were supported in maintaining a responsibility for aspects of their own extended personal care and maintaining independence in this area. This was specifically in respect of laundry and ironing. Service users are supported by care staff in accessing local community facilities. On the morning of the inspection three service users made use of local hairdressing services and at lunch time a small group went out for lunch. These activities were described by staff as normal activities within the lives of service users.Standard 12 (12.1 ­ 12.6) Staff help service users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities 3 Key findings/Evidence Standard met? The service users living within this service represent a wide age range from 50 to late 70s, the aspirations within the group are therefore quite varied. There is a clear commitment to provide access to a range of social activities, these include, local pubs, theatres, shops, museums and trips to various places of interest. There is within the service user group a small number of individuals who access a range of employment situations.Lodge Lane Mental Nursing HomePage 17 Standard 13 (13.1 ­ 13.5) Staff support service users to become part of, and participate in the local community in accordance with assessed needs and the individual Plans. 3 Key findings/Evidence Standard met? As stated in standard 12, service users either access and make use of the facilities within the local community of Bewsey on their own or with appropriate staff support.Standard 14 (14.1 ­ 14.6) Staff ensure that service users have access to and choose from a range of appropriate leisure activities. 3 Key findings/Evidence Standard met? Service users make use of local facilities to provide a range of satisfying, meaningful and enjoyable activities.Standard 15 (15.1 ­ 15.5) Staff support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection but will be assessed at the next.Standard 16 (16.1 ­ 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? All of the service users within this service have been provided with keys to their bedrooms, within which there additional lockable facilities. Any restrictions on movement outside of the service have been based pond specific risk assessments and details of these decisions have been included within care plans and explained to the service users in question.Lodge Lane Mental Nursing HomePage 18 Standard 17 (17.1 ­ 17.9) The registered person promotes service users health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 0 Key findings/Evidence Standard met? This standard was not assessed at this assessment but will be assessed at the next.Lodge Lane Mental Nursing HomePage 19 Personal and Healthcare SupportThe intended outcomes for the following set of standards are: · · · · 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 homes policies and procedure for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish.Standard 18 (18.1 ­ 18.11) Staff provide sensitive and flexible personal support and nursing care to maximise service users privacy, dignity, independence and control over their lives. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection but will be assessed at the next.Standard 19 (19.1 ­ 19.5) The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. No. of incidents where service users have been taken to Accident & Emergency during last 12 months No of service users with pressure sores at the time of inspection (from information taken from care notes) X00 Key findings/Evidence Standard met? This standard was not assessed at this inspection but will be assessed at the next.Lodge Lane Mental Nursing HomePage 20 Standard 20 (20.1 ­ 20.14) The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the homes policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 3 Key findings/Evidence Standard met? There was no record of service users taking responsibility for the administration of their own medication. The storage of medication and the provision if necessary for the control of medicines liable to misuse was secure. Records examined were up-to-date and corresponded to medication administered. Nursing staff spoken with were aware of their own professional responsibilities under the Nursing and Midwifery Council, Code of Professional Practice.Standard 21 (21.1 ­ 21.8) The registered manager and staff deal with the ageing, illness and death of a service user with sensitivity and respect. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection but will be assessed at the nextLodge Lane Mental Nursing HomePage 21 Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: · · Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm.Standard 22 (22.1 ­ 22.7) The registered person ensures that there is a clear and effective complaints procedure which includes the stages of and times-scales for the process and that service users know how and to whom to complain. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to NCSC Percentage of complaints responded to within 28 days X X X X X X 100 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection but will be assessed at the next.Lodge Lane Mental Nursing HomePage 22 Standard 23 (23.1 ­ 23. 6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, or inhuman or degrading treatment, through deliberate intent, negligence, or ignorance, in accordance with written policy. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists YES00 Key findings/Evidence Standard met? This standard was not assessed at this inspection but will be assessed at the next.Lodge Lane Mental Nursing HomePage 23 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 24 (24.1 ­ 24.13) The homes premises are suitable for its stated purpose; accessible, safe and well maintained; meet service users individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. 3 Key findings/Evidence Standard met? The general appearance of the home was of a well maintained and comfortable place to live. There is a large lounge on the ground floor with a conservatory extension. There is an additional smaller quite lounge on the first floor and a designated sensory room. Previously identified requirements to re-carpet the corridor has been positively responded to.Lodge Lane Mental Nursing HomePage 24 Standard 25 (25.1 ­ 25. 11) The registered person provides each service user with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyles. Total no. of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1st April 2003) ­ single bedrooms below 10 sq.m usable space or additional compensatory space Total no. of wheelchair users accommodated for in rooms at least 12 sq.m Total no. of wheelchair users accommodated for in rooms less than 12 sq.m Total no. of shared rooms at least 16 sq.m Total no. of shared rooms below 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total no. of single bedrooms Number of single bedrooms with en suite Total no. of double bedrooms Number of double rooms with en suite YES NO NO 20 0 0 0 20X X X X X3 Key findings/Evidence Standard met? Each of the bedrooms within this service are decorated and personalised to reflect the character and choices of the occupants. Each bedroom viewed on this inspection was furnished to a commendable standard. All bedrooms are provided with over-ridable locks, that are acceptable to the fire authority. Service users are provided with keys to their bedrooms.Lodge Lane Mental Nursing HomePage 25 Standard 26 (26.1 ­ 26.4) The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. 3 Key findings/Evidence Standard met? The bedrooms viewed had a good standard of soft furnishings that were individualised and different in each bedroom viewed. Bedroom furniture was also of a good quality, whilst there was only one comfortable chair provided in each bedroom, the provision of a second chair would have a negative effect on the available floor space and a considered decision has been made not to provide this facility.Standard 27 (27.1 ­ 27.6) The registered person provides service users with toilet and bathroom facilities which meet their assessed needs and offer sufficient personal privacy. 3 Key findings/Evidence Standard met? There are within this service four bathrooms with WCs these provide two specialised and assisted facilities. There are also three showers, one of which is a walk in type suitable for people with a disability and a separate a shower table. Within the service are four single toilets. All doors are provided with over-ridable lockable facilities.Standard 28 (28.1 ­ 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 3 Key findings/Evidence Standard met? As stated in standard 24 there are a number of separate communal areas in the form of sitting rooms and smoking area. There are also two dining rooms, providing opportunities for diversity and change within daily routines. Within this service is also a craft room where service users have displayed various displays of their handiwork.Lodge Lane Mental Nursing HomePage 26 Standard 29 ( 29.1 ­ 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the homes stated purpose and the individually assessed needs of all service users. 0 Key findings/Evidence Standard met? This standard was not assessed but will be assessed at the next.Standard 30 (30.1 ­ 30.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of inspection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 3 Key findings/Evidence Standard met? There are within the main policy folder for this service specific policies relating to the control of infection and the maintenance of a clean and safe environment. Conversation with a member of staff responsible for domestic routines confirmed her understanding of her role and responsibility. This member of staff was also aware of the regulations relating to the control of substances hazardous to health (COSHH). A tour of the premises confirmed the cleanliness of the service and the absence of obvious malodours.Lodge Lane Mental Nursing HomePage 27 StaffingThe intended outcomes for the following set of standards are: · · · · · · 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 homes 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.Standard 31 (31.1 ­ 31.7) The registered manager ensures that staff have clearly defined job descriptions and understand their own and others roles and responsibilities. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection but will be assessed at the next.Lodge Lane Mental Nursing HomePage 28 Standard 32 (32.1 ­ 32.6) Staff have the competencies and qualities required to meet service users needs and achieve Sector Skills Council workforce strategy targets within the required timescales. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. Personal Care No. service users High needs No. service users Medium needs No. service users Low needs Total no. of hours needed No. of staff with NVQ level 2 or above No. of Trainees registered on Sector Skills Council training programme X X X X X No. of full time equivalent Staff with nursing qualification (where applicable) No. staff hours allocated No. staff hours allocated No. staff hours allocated Total Hours Provided X X X X Nursing X X XXX0 Key findings/Evidence Standard met? This standard was not assessed at this inspection but will be assessed at the next.Standard 33 (33.1 ­ 33.11) The home has an effective staff team with sufficient numbers and complementary skills to support service users assessed needs at all times. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection but will be assessed at the next.Lodge Lane Mental Nursing HomePage 29 Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection but will be assessed at the next.Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection but will be assessed at the next.Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. 3 Key findings/Evidence Standard met? During his inspection it was observed that there was a schedule of staff supervision on the wall of the office. This identified that the staff team is supervised by the qualified nurses who in turn are supervised by the manager. This process provides for a minimum of six supervision sessions a year. The subjects covered were confirmed as including; work performance, relationships with service users and staff, training and personal development.Lodge Lane Mental Nursing HomePage 30 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: · · · · · · · 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 homes policies and procedures. Service users rights and best interests are safeguarded by the homes 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.Standard 37 (37.1 ­ 37.4) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Registered manager qualified to level 4 NVQ in Management and care or equivalent. NO3 Key findings/Evidence Standard met? The registered manager is a qualified nurse, with a specific qualification in mental health nursing (RMN). The manager has managed this service since its opening in 1992. The manager stated at this inspection that she has committed herself to starting an NVQ in management in January 2004.Standard 38 (38.1 ­ 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection but will be assessed at the next.Lodge Lane Mental Nursing HomePage 31 Standard 39 (39.1 ­ 39.10) Effective quality assurance and quality monitoring systems based on seeking the views of service users are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection but will be assessed at the next.Standards 40 (40.1 ­ 40.6) The homes written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Younger Adults. 3 Key findings/Evidence Standard met? There was within this service a comprehensive policy folder containing a wide range of policy documents. Staff have signed to confirm that they have read these documents.Standard 41 (41.1 ­ 41.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained up to date and accurate. 0 Key findings/Evidence Standard met ? This standard was not assessed at this inspection but will be assessed at the next.Lodge Lane Mental Nursing HomePage 32 Standard 42 (42.1 ­ 42.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 2 Key findings/Evidence Standard met? Staff have received training in moving and handling procedures, breakaway techniques, food handling & hygiene, fire safety and first aid. Records are maintained to evidence the maintenance of all equipment within the service including; hoist, pressure relieving mattresses and beds. A notable exception was an absence of record to confirm the maintenance of the gas heating system, An immediate requirement was made to make good this shortfall. See Requirement No 1.Standard 43 (43.1 ­ 43.7 ) The overall management of the service (within or external to the home) ensures the effectiveness, financial viability and accountability of the home. 0 Key findings/Evidence Standard met ? This standard was not assessed at this inspection but will be assessed at the next.Lodge Lane Mental Nursing HomePage 33 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DateJohn Mills Julie HuntSignature Signature SignatureLodge Lane Mental Nursing HomePage 34 PART DLAY ASSESSORS SUMMARY(where applicable) There was no Lay Assessor at this inspection.Lay Assessor Date Public reportsSignatureIt should be noted that all NCSC inspection reports are public documents.Lodge Lane Mental Nursing HomePage 35 PART EE.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 12th December 2003 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleAction taken by the NCSC in response to provider comments: Lodge Lane Mental Nursing Home Page 36 Amendments to the report were necessaryNOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateNONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. E.2 Please provide the Commission with a written Action Plan by 15th March 2004, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request.You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESOther: enter details here Lodge Lane Mental Nursing HomePage 37 E.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.E.3.1 I Mr D Matthews of Warrington Community Care confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on 12th December 2003 and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or E.3.2 I Mr D Matthews of Warrington Community Care am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on 12th December 2003 for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Lodge Lane Mental Nursing HomePage 38 - 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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