Inspection on 17/08/06 for Lodge (The)

This inspection was carried out on 17th August 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lodge (The) 05/03/09

Lodge (The) 14/03/08

Lodge (The) 28/12/05

Lodge (The) 13/10/05

Lodge (The) 26/07/04

Lodge (The) 13/04/04

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Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Lodge (The) Lodge (The) Roman Way Farnham Surrey GU9 9RE Lead Inspector Pat Collins Unannounced Inspection 17th August 2006 10:10 Lodge (The) DS0000013584.V308272.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 Lodge (The) DS0000013584.V308272.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. Lodge (The) DS0000013584.V308272.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lodge (The) Address Lodge (The) Roman Way Farnham Surrey GU9 9RE 01252 717021 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) Ability Housing Association Ms Sandra Alexandra Passingham Care Home 5 Category(ies) of Learning disability (3), Learning disability over registration, with number 65 years of age (2) of places Lodge (The) DS0000013584.V308272.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. In addition to the primary condition Learning Disability up to 3 (three) service users below the age of 65 years may be within the category PD - Physical Disability and 2 (two) within the category SI - Sensory Impairment. In addition to the primary condition Learning Disability up to 2 (two) service users above the age of 65 years may be within the category PD (E) Physical disability and 1 (one) within the category SI (E) Sensory impairment. 28th December 2005 2. Date of last inspection Brief Description of the Service: The Lodge is a care home providing personal care for five adults with learning disabilities. Service users may have a physical disability or sensory impairment as secondary conditions. Two of the service users are over the age of 65 years and the group is mixed gender. The home is situated in a residential area on the outskirts of Farnham and is within walking distance of the town centre. The home is accessible to public transport and all community amenities. The accommodation is all on one level and most areas are wheelchair accessible. The environment is domestic in scale and character and bedroom accommodation is all single occupancy. The lounge is comfortably furnished and the dining room is separate. The kitchen has been designed to enable wheelchair users to access appliances and work surfaces. Provision includes an assisted shower and disabled toilet also suitable aids and equipment. Service users have access to an enclosed, furnished garden that is shared with the tenants of an adjacent ‘supported living’ service. Parking facilities are available and service provision includes a wheelchair accessible vehicle. The home is managed by Ability Housing Association, a registered charity specialising in housing, care and support for people with disabilities. A registered manager is employed at The Lodge. At the time of this inspection weekly fee charges were £833.64.Additional charges included hairdressing, some social activities, toiletries, clothing, holidays and use of the house vehicle at 40p per mile. Information about the home’s services and facilities are detailed in a statement of purpose and service users guide, which is available from the home. Lodge (The) DS0000013584.V308272.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first key inspection of the home, drawing together the cumulative assessment, knowledge, and experience of service provision since the last inspection in December 2005. This inspection also takes account of observations during an unannounced inspection visit undertaken by one regulation inspector on 17th August 2006. The duration of this visit was eight and a half hours at which time all key national minimum standards for adults were inspected. A tour of the premises was undertaken and records, policies and procedures were sampled. Staff and those service users present were consulted and a brief discussion took place with the home manager at the time of the feedback session. Written comments received from four service users also informed the inspection. Service users are referred to as ‘tenants’ I the report in accordance with the expressed preference of those consulted in this matter. The inspector would like to thank all who contributed to the inspection process. What the service does well: The environment is domestic in scale and character and its management and operation was caring and enabling. Tenants received sustained encouragement, instruction and stimulation as continuing elements in their daily lives. Staff were observed during the inspection visit providing guidance and encouragement to a tenant in planning her weekly menu and cooking her evening meal. Tenants were encouraged to develop and practice independence skills through assessment and care planning processes. A tenant stated how much he valued having his own bedroom and that staff respected his privacy. Over the last twelve months a programme of redecoration and upgrading work had improved the living environment. The kitchen had been refurbished and included some wheelchair accessible units and appliances. A new shower chair and washing machine had also been purchased. All areas of the home were clean and comfortable and bedrooms were personalised. The day – day operation of the home valued tenants’ diversity and promoted equal opportunities within individual capacities. Observation made of practice and information obtained from records, staff and service users indicated good understanding of the social model of disability. The rights, choices and responsibilities of tenants were being promoted and staff’s approach to tenants was age-appropriate. Tenants engaged in a range of appropriate activities inside and outside of the home, in accordance with individual interests and aspirations. Escorted holidays in small groups had taken place this year. During the inspection visit two tenants arrived back from a holiday in Wales. The home manager and Lodge (The) DS0000013584.V308272.R01.S.doc Version 5.2 Page 6 senior support worker had accompanied them. Tenants were supported in maintaining family relationships and friendships. Minutes of tenants meetings demonstrated that staff listened and took on board their suggestions and opinions when making decisions about the running of the home. Examples included decisions about décor and new furnishings. A person centred approach was evident in the personalising of bedrooms. Tenants were empowered by the attention given to communication. Significant information had been reproduce in accessible formats using pictorial and symbol images. This included the complaint procedure, safety notices, menus, minutes of meetings, service users guide and charter of rights Tenants physical and emotional health needs had been identified and action taken to access appropriate services. Tenants were involved in selecting menus and had a choice of food. The home was clean and comfortable and a routine maintenance programme was in place. 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 Lodge (The) DS0000013584.V308272.R01.S.doc Version 5.2 Page 7 contacting your local CSCI office. Lodge (The) DS0000013584.V308272.R01.S.doc Version 5.2 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 Lodge (The) DS0000013584.V308272.R01.S.doc Version 5.2 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, 3, 4 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The information available to prospective tenants and their representatives about the home was comprehensively produced in suitable formats. This enabled an informed choice about the home’s suitability. Attention was drawn to amendments necessary to the service users guide document in response to recent amendments to the Care Homes Regulations. Policy and procedures for pre-admission assessments ensured prospective tenants needs and aspirations were identified and met. EVIDENCE: The home’s statement of purpose depicted service provision and contained all statutory elements. Tenants had been involved in producing the service user guide in an accessible format using language and symbols to aid comprehension. Attention was drawn to recent amendments to the Care Homes Regulations 2001 and implications of this for the home. The service user guide document must be amended to reflect these amendments. Lodge (The) DS0000013584.V308272.R01.S.doc Version 5.2 Page 10 There had been no admissions since the last inspection. Records sampled demonstrated that in the past prospective tenants had received a full and comprehensive assessment of needs prior to moving into the home. Background information had been collated prior to admission to enable assessment of risks and identify individual strengths, needs and aspirations. Prospective tenants had opportunity to visit the home and to get to know other tenants prior to admission. Admissions were on the basis of trial placements. Lodge (The) DS0000013584.V308272.R01.S.doc Version 5.2 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, 8, 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Tenants were aware of their care plans and involved in drawing these up. Those sampled were clearly written, reflecting needs, goals and assessed risks. A person centred approach was central to the home’s management and operation. The home had a strong ethos of involving tenants in decisions affecting their lives and the running of their home. EVIDENCE: Discussions with individual tenants established they were aware of their care plans within individual levels of capacity. The care plans sampled were holistic and had been recently reviewed. Risk assessments, behaviour management guidelines as necessary, personal, health and social care plans were in place. Tenants’ were involved in the running of their home to the extent they wished to be. They had choice about their lifestyles, based on assessment of needs and personal aspirations. Tenants were noted to take an active role in menu planning. Staff advised they encouraged their involvement in shopping for food and preparation of meals and in domestic routines. Staff acknowledged that only two tenants regularly engaged in these activities however. Lodge (The) DS0000013584.V308272.R01.S.doc Version 5.2 Page 12 Minutes of meetings between tenants and staff demonstrated an inclusive approach to decision making in the day-to-day operation of the home. Two tenants commented in feedback cards that they did not like specific behaviour of a service user. Records of meetings and care programmes confirmed staff were appropriately responding to this issue. Describing what was good about living at the home, comments received from tenants’ demonstrated ownership of their own home. Examples include “ you can come and go when you like and I like the people here”, “it is nice and clean here and staff treat me well” “ I like living here, I go out” and “I like making tea and coffee and helping out”. Lodge (The) DS0000013584.V308272.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 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. The home meets each of these assessed standards very well. It was demonstrated that tenants were encouraged and supported to lead fulfilling lives. They were enabled to integrate in the community and supported in maintaining family links. Tenants enjoyed a healthy, varied diet and were offered choice of food. EVIDENCE: Tenants were observed to receive sustained encouragement, instruction and stimulation as continuing elements in their daily lives. Life skills training opportunities were available and they received support with budgeting and managing their personal finances. It was evident from the available information that arrangements existed for individuals’ with complex needs to receive specialist interventions and services. Tenants had opportunity to access and use community facilities and resources. On the day of the inspection visit a tenant went shopping for food accompanied Lodge (The) DS0000013584.V308272.R01.S.doc Version 5.2 Page 14 by a Mencap worker. This tenant had prepared a weekly menu and drawn up a shopping list with staff guidance. On her arrival back at the home she put her shopping away and reviewed her menu. It was positive to note that this individual had received basic food hygiene certificated training. Other tenant reported engaging in menu planning activities with staff using visual prompts of meals to aid recall and decision-making. The meal served in the dining room on the evening of the inspection had been prepared by a support worker. This was substantial and appetising. Staff and tenants ate the meal together at the dining table, joined by individuals who had just arrived back from holiday. The mealtime was observed to be a social occasion. A range of information supplied to tenants also support from staff enabled them to make informed choices in their daily lives. Care plans indicated suitable arrangements for stimulation and tenants’ involvement in community events and educational and vocational activities. A tenant spent the morning of the inspection visit at a day centre. Another tenant informed the inspector that he enjoyed music therapy sessions, which was a relatively new therapeutic activity. He also stated how much he liked swimming at a hydrotherapy pool and that his favourite activity was wheelchair ice-skating. The home had a policy statement, which promoted equality and diversity, and there was evidence of these being put into practice. Arrangements ensured religious needs were met and the operation of the home promoted equality between male and female tenants. Staff were aware of barriers to people with disabilities leading an independent life and strived to tenants in overcoming the same. A tenant informed the inspector of waiting to commence a trial period of assessment at another establishment, which would further enhance this individual’s potential to live in a more independent environment. Tenants had opportunity to go on holiday. Earlier this year two individuals had holidayed in a caravan in Weymouth supported by staff. Two other tenants returned from an escorted holiday in Wales during the course of the inspection visit. The home manager and senior support worker had accompanied them. It was good to note arrangements during this holiday for one of the tenants to meet up with relatives who live in Wales. Lodge (The) DS0000013584.V308272.R01.S.doc Version 5.2 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, 21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The preferences of tenants’ were being accommodated in the delivery of personal care and staff respected their right to privacy and dignity. It was recommended that a call bell be placed beside the toilet in the shower room to further promote independence. Personal care practice was noted to be regularly discussed at staff meetings to ensure an appropriate balance between staff’s duty of care and the rights of tenants to exercise control over their lives. Arrangements were in place to ensure physical and health care needs were met and specialist services and advice sought as necessary. Whilst medication practices overall promoted service users health attention was required to an area of practice. Ageing, illness and death of service users was managed appropriately and with sensitivity. EVIDENCE: Lodge (The) DS0000013584.V308272.R01.S.doc Version 5.2 Page 16 The home’s routines for getting up/going to bed, meals and other activities were reasonably flexible, structured by pre arranged personal social, leisure and training programmes and tenants’ individual preferences. Personal intimate care and support practice, on the day of the inspection, were carried out in private. Based on available information it was concluded that core values and principles of privacy, dignity, independence, choice, rights, fulfilment and individuality were enshrined in the operation of this home. All tenants were registered with a general practitioner and had access to primary and specialist health services in accordance wit assessed needs. Discussions at the time of the inspection visit included staff training and support in the management of stoma care and epilepsy. Recommendation was made for provision to be made of antibacterial hand wash to enhance infection control procedures. Observations in the management of administration of prescribed medication for treatment of multiple or prolonged seizures which could be potentially life threatening, identified this as an area of practice requiring further review. It is acknowledged that since the last inspection effort had been made to clarify in what circumstances and the time frame in which this drug should be administered. Also to source staff training which had been unsuccessful. The manager had ensured in-house instruction to staff however individual staff were not confident in their competence to administer this drug in a safe and effective manner for the emergency treatment of seizures. This was fully discussed with the home manager who took immediate action to provide staff with interim instructions for the management of these seizures for the individuals concerned, pending further staff training. Discussed was the need to ensure clear individual seizure management plans were developed with review dates; also clearer guidelines for administration of this drug and a formal written protocol. All potential administrators of this medication must be trained in its use and arrangements for responding to these seizures agreed with medical practitioners for times when these staff members are not on duty. Medication storage and record keeping systems were found to be satisfactory. It was noted that assessments were planned for provision of a hoist to meet the needs of two tenants. Lodge (The) DS0000013584.V308272.R01.S.doc Version 5.2 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 excellent. This judgement has been made using available evidence including a visit to this service. The complaint procedure was accessible to tenants and their relatives and representatives. Tenants were also protected by the organisation’s recruitment practices. The whole team had received training in safeguarding vulnerable adults and new staff received this training as part of their induction. EVIDENCE: The complaint procedure was displayed in a user-friendly format on the notice board in the dining room. All complaints were recorded and taken seriously. Observations confirmed staff’s willingness to listen to tenants and take seriously and act on any issues and concerns and complaint they raised. The establishment had a copy of local multi-agency safeguarding vulnerable adult procedures. There had been no investigations or referrals under these procedures since the last inspection. Staff recruitment procedures protected tenants by ensuring checks made against the POVA list for all new staff prior to taking up post. These staff then worked under supervision until receipt of their CRB Disclosure. The staff team had received adult protection training and staff had access to the organisation’s whistle blowing procedure. Those interviewed were clear of what action to take in the event of allegations or suspicions of abuse. . Lodge (The) DS0000013584.V308272.R01.S.doc Version 5.2 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, 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. This family-scale home provides a comfortable, good standard of accommodation suitable to the needs and lifestyles of those accommodated. The home was clean and hygienic and overall designed to maximise independence. EVIDENCE: The location of the home near to community facilities was suitable for its stated purpose. A ramp was fitted to the front door, which had an automatic opening/closing device. Ramped access to the garden was provided and good quality garden furniture provided. All areas of the home were nicely decorated following a programme of redecoration last year. Individual tenants stated they valued having their own bedrooms and that staff respected their privacy. The kitchen was also refurbished last year to a good standard making provision of wheelchair accessible work surfaces, some appliances and sink unit. A new shower chair had been purchased. All areas viewed were clean and comfortable and the bedrooms sampled had been personalised. Infection control procedures and practices were not assessed in any depth. It was noted however that adequate Lodge (The) DS0000013584.V308272.R01.S.doc Version 5.2 Page 19 supplies of disposable gloves and aprons were available and yellow bag clinical waste disposal arrangements were in place. The number of toilet and bathing facilities were adequate and these were fitted with appropriate aids and adaptations. It was recommended for a call bell to be positioned beside the toilet in the shower room. Hot water temperatures were routinely monitored and this had identified the need for adjustment by an engineer. This took place on the day of the inspection visit and remedial action taken to reduce excessively hot water temperatures in some areas. Provision of equipment was made to meet individual needs included shower chair, grip rails, raised toilet seats, walking aids, wheelchairs and emergency call system. Observations confirmed strategies to be in place to enable tenants with visual impairments to safely navigate their way around the home. Communication aids included pictorial and symbol formats used in documents providing information used by tenants. Lodge (The) DS0000013584.V308272.R01.S.doc Version 5.2 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): 31, 32, 33, 34, 35 Quality in the outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff on duty demonstrated commitment to supporting tenants in a way that enabled expression of individuality and recognised their rights, values and aspirations. It was perceived that staff worked as a team and there was a programme of staff training to equip them with the necessary skills and knowledge to fulfil their role. They acknowledged one area of practice in which they required further training. Based on available information it was concluded that staff recruitment procedures were satisfactory. EVIDENCE: Staff on duty were observed to be caring and professional in their interaction with tenants. A tenant expressed the view that “staff are nice”. Support workers had generic roles and were responsible for ancillary duties in addition to responsibilities for personal care and support. Three support workers were no longer in post since the last inspection. Two new support workers had since been recruited and taken up post. It was stated that vacancies for a full and part time support worker had also been recently been filled. Staff expressed the view that staffing levels were adequate which included comment on night staffing levels. The home’s usual staffing levels were two staff throughout the waking day and one waking staff at night. Noting Lodge (The) DS0000013584.V308272.R01.S.doc Version 5.2 Page 21 reference made to CSCI endorsement of the adequacy of one waking night staff in this establishment in the August providers report it must be noted that it is the responsibility of management to be satisfied of the adequacy of staffing levels to ensure the safety and welfare of tenants and staff. Systems need to be in place for regular monitoring and review of staffing levels based on assessed needs and risks, which can substantially change between inspections. The relevant Residential Forum staffing tool should be used as a guide in determining minimum staffing levels. Staffing levels had been reduced whilst tenants were on holiday. On –call arrangements were I place in the event of staff needing assistance or advice. Despite the significant staff turnover in this small team continuity of care was being maintained through inevitably the key worker system had been disrupted. Discussions with a new employee confirmed comprehensive staff recruitment and vetting procedures had been adhered to and she was in receipt of a job description. Staff job descriptions were noted to be under review. This member of staff reported an induction and core-training programme in progress during the six months probationary period. of her employment. Staff had training and development plans and had received recent training in use of the computer to enable them to fulfil the full range of their duties. A programme of statutory training for staff was evident, which included Learning Disability Award Framework accredited training. A number of staff had qualifications in care and two on duty confirmed their intention to enrol for NVQ Level 3 certificates. The staff turnover had affected the home’s ability to comply with the standard for 50 of staff excluding the manager to have NVQ level 2 qualifications in care or equivalent. It is acknowledged that at the time of the inspection 50 of staff had been in post for less than one year. Lodge (The) DS0000013584.V308272.R01.S.doc Version 5.2 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, 38, 39, 40, 41, 42 Quality in the outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s administration was efficient and organised and tenants benefited from the ethos, leadership and management approach of the home. Quality assurance and quality monitoring systems involved consultation with tenants. . Policies and procedures safeguarded tenants rights and best interests. EVIDENCE: Lodge (The) DS0000013584.V308272.R01.S.doc Version 5.2 Page 23 The home manager was not present until the time of feedback at the time of arriving back from escorting two tenants on holiday. Staff in charge of the early and late shift competently facilitated the inspection process. The home manager had relevant skills and experience and was registered by the Commission for Social Care inspection. She had a management qualification. At the time of the last inspection the manager had been studying for the Registered Manager in Care Award, NVQ Level4. It was not established whether this qualification had since been attained. A senior support worker usually deputized for the manager in her absence. Staff on duty at the time of the inspection visit stated that on-call arrangements were in place in the event of their need for advice and support whilst the home manager and her deputy were away with tenants. They stated they would contact the team leader in charge of the organisation’s supported living establishment next door. The home’s fire procedure had been revised and two night fire evacuation procedures carried out since the last inspection. These had highlighted some areas for attention. Specifically additional external lighting, which had been carried, out and key for a gate. Work was planned to fit a handrail for wheelchair users at one fire exit. A programme of routine risk assessments and maintenance checks was noted. Regular monitoring of hot water temperatures was undertaken and had identified excessive hot water temperatures in some areas. A plumber rectified this on the day of the inspection visit. Incident reports were adequately recorded and monitored by the manager with appropriate follow up as necessary. Quality audit systems were in operation and quality assurance systems included invitations for tenant representatives to meet others from services managed by this organisation and senior management to give feedback and constructive suggestions for improvement. Monthly statutory provider visits were carried out by a team leader from other establishments and findings produced in reports. These reports were sent to senior management, the home manager and CSCI. Staff conferences were held annually at which staff were encouraged to express their views and make suggestions. The organisation also convened working parties where policies and procedures were reviewed and staff and tenants invited to contribute to this process. Observations concluded that overall the home was effectively managed and administered to meet its stated purpose. There was evidence of policies and procedures put into practice; also clear lines of accountability within the home and within external management. Staff informed the inspector that the service manager visited the home on a regular basis. Lodge (The) DS0000013584.V308272.R01.S.doc Version 5.2 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 3 4 3 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 3 32 2 33 3 34 3 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 3 3 3 x 3 3 x Lodge (The) DS0000013584.V308272.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 4 (1) Requirement Timescale for action 17/10/06 2. YA1 5(1)(bd) 3. YA20 YA32 YA35 13(2) 4. YA20 YA42 13(2) For a copy of an up to date statement of purpose for the home to be supplied to the CSCI. For review of the service users 17/10/06 guide to include additional information in accordance with recent amendments to the Care Homes Regulations 2001. For the home to have a 17/10/06 written protocol for administration of Epistatus Buccal Midazolam and staff trained in its use. It is recommended that individual seizure management plans be drawn up underpinned by prescribing medical practitioners instructions for administration and when it should not be administered and emergency services should be contacted. Seizure management plans should be subject to regular review. Until such time as requirement 18/08/06 3 is met for management to consult the home’s GP on the appropriate management prolonged tonic-clonic seizures DS0000013584.V308272.R01.S.doc Version 5.2 Lodge (The) Page 26 5. YA32 and staff instructed accordingly. 18(1)(a)(c)(i) For 50 of support workers including agency staff to have qualifications in care at NVQ Level 2 or equivalent. An action plan with timescale for compliance with this requirement must be forwarded to the CSCI. 17/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA3 YA24 YA19 YA33 Good Practice Recommendations For a call bell to be installed beside the toilet in the shower room. For provision of antiseptic hand wash or alcohol based hand rub for staff use as part of the home’s infection control procedures. For review of current arrangements for monitoring and review of staffing levels and ensure use of the appropriate Residential Forum’s staffing tool for this purpose in determining minimum levels. Lodge (The) DS0000013584.V308272.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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