Inspection on 28/12/05 for Lodge (The)

This inspection was carried out on 28th December 2005.

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

The inspector found no outstanding requirements from the previous inspection report, but made 12 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) 17/08/06

Lodge (The) 13/10/05

Lodge (The) 26/07/04

Lodge (The) 13/04/04

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

CARE HOME MIXED CATEGORY MAJORITY ADULTS 18-65 Lodge (The) Lodge (The) Roman Way Farnham Surrey GU9 9RE Lead Inspector Pat Collins Unannounced Inspection 10:30 28 December 2005 th Lodge (The) DS0000013584.V273403.R01.S.doc Version 5.0 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.V273403.R01.S.doc Version 5.0 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 Older People and 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.V273403.R01.S.doc Version 5.0 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.V273403.R01.S.doc Version 5.0 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. 13th October 2005 2. Date of last inspection Brief Description of the Service: The Lodge is a care home providing personal care for up to five adults with learning disabilities. Service users may have a physical disability or sensory impairment as a secondary condition. The current service users group is mixed gender and two service users are over 65 years of age. The home is situated in a residential area on the outskirts of Farnham and within walking distance of the town centre. The home is served by public transport and accessible to all community amenities. The accommodation is all on one level and wheelchair accessible with the exception of the utility room. The environment is domestic in scale and character and bedroom accommodation is all single occupancy. The communal lounge is comfortably furnished and there is a separate dining room. The kitchen has been designed to enable wheelchair users to access some appliances and work surfaces. Provision includes suitable assisted shower and toilet facilities, also aids and equipment including hoist. Service users have access to an enclosed garden. This is shared with the tenants of an adjacent property providing supported living accommodation, under separate management by the same organisation. Parking facilities are available and service provision includes a wheelchair accessible vehicle. The home is managed by Ability Housing Association, which specialises in services providing housing, care and support for people with disabilities. A full time registered manager is employed who is solely responsible for the day-today management of The Lodge. Lodge (The) DS0000013584.V273403.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the home’s second inspection for the year 2005/2006. It was unannounced therefore staff and service users were not informed in advance of the inspection being carried out. The inspection commenced at 10.30 hrs and concluded at 13.30 hrs. The manager and two support workers were on duty. The inspection process involved reviewing progress made for compliance with statutory requirements at the time of the last inspection. A partial tour of the home was conducted and a sample of records examined. The inspector engaged in discussions with the manager and both support workers and individually with all service users. The inspector would like to thank the service users and staff for their courtesy and cooperation throughout the inspection. What the service does well: The manager and support workers on duty were observed in their interaction with service users. They were respectful and age-appropriate in their manner of address towards service users. Staff demonstrated good knowledge of service users’ needs, ensuring appropriate methods of communication and ensured provision of an enabling and inclusive environment. They promoted service users’ choice and independence, within a risk management framework and individual limitations. The care records demonstrated overall satisfactory attention to service users personal and healthcare support needs. Service users described having spent an enjoyable Christmas engaging a range of stimulating, seasonal activities leading up to the Christmas and New Year festivities. They had had opportunity to spend quality time with families and friends. One service user spent Christmas day with his family and the remainder of the group accepted an invitation to have Christmas dinner out at a local venue, accompanied by support workers. This was organised as an annual event by a charitable Church group. Service users stated that they had enjoyed the activities and entertainment provided and socialising with others also invited, living independently in the community. The complaint procedure was observed to be effective and accessible to service users. Service users views were evidently taken into account in planning the operation of their home and were seen to underpin self – monitoring systems. Lodge (The) DS0000013584.V273403.R01.S.doc Version 5.0 Page 6 Staff files sampled demonstrated arrangements for new staff to receive induction training and a programme of continuous staff training and development was in place. What has improved since the last inspection? What they could do better: The fire risk assessment would benefit from further development and the frequency of fire practices needs to be reviewed. Observations of records relating to a recent incident identified failure to adhere to the home’s on –call procedures by the staff member in charge. Attention was required to aspects of the management of epilepsy for an individual service user to ensure relevant protocols in place. This must be in sufficient detail for responding to prolonged seizures following clarification of medical instruction for administration of new medication for this purpose. Additionally staff training for administration of this drug was also required for all staff responsible for medication administration. The manager must ensure that the above protocol is available for information of the relevant day services staff for the same individual. The manager must also liaise with the pharmacy to ensure this medication supplied to the home is recorded on a medication administration record and labelled to reflect instructions for administration of this variable dose medication. Brought forward from the requirements of the last inspection is improvement required to recruitment practices and personnel records. Additionally new staff may not take up post unless a POVA/First check is carried out prior to obtaining a CRB Disclosure. Those employed on this basis also must be supervised in the delivery of personal care until receipt of their CRB Disclosures. A CRB record must be maintained as previously discussed and Lodge (The) DS0000013584.V273403.R01.S.doc Version 5.0 Page 7 personnel records held in the home contain copies of all statutory information including recent staff photographs. It is necessary to ensure visits made on behalf of the responsible individual are carried out on a monthly basis. 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. Lodge (The) DS0000013584.V273403.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) Lodge (The) DS0000013584.V273403.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected on this occasion. At the time of the last inspection the home was operating effectively in respect of these standards. EVIDENCE: Lodge (The) DS0000013584.V273403.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14, and 33 (Older People) 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 Evidence gathered demonstrated that mostly these standards were effectively met to ensure service users individual needs and wishes were recognised and appropriately met. Comments for improvement to documentation and practice for management of seizures for a named service user are detailed in the section of this report specific to standard 19. EVIDENCE: The care plans sampled were up to date. Discussions with individual service users established they were aware of their care plans within individual levels of understanding. Two service user plans were sampled and information therein found to be well organised. Risk assessments, behaviour management guidelines if needed, personal, health and social care plans were in place. Comments on improvement required to care documentation specific to the management of epilepsy for a named individual are recorded under standard Lodge (The) DS0000013584.V273403.R01.S.doc Version 5.0 Page 11 19. Service users made decisions about their lives with the necessary assistance required. A service users needs had been assessed and an alternative placement was being sought to accommodate this persons needs more appropriately and improve the safety of this environment for other, more vulnerable service users. There were systems for involving service users in planning menus, in shopping for food and in food preparation. Individual programme plans promoted independence. A service user prepared her own cooked lunch under discreet supervision of a staff member Service users informed the inspector that staff supported and encouraged them to clean and tidy their rooms. Staff facilitated access and use of community facilities. Service users choice and involvement in running the home was evidently of high importance to staff. The day-to-day operation of the home ensured user choice regarding their lifestyles, based on assessment of needs and personal aspirations. Minutes of service users meetings demonstrated regular consultation with service users and their involvement in decisions regarding their home. Lodge (The) DS0000013584.V273403.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. Service Users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. Service users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) 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. The home met each of these standards. It was demonstrated that service users were encouraged and supported to be as independent as they could be and to lead fulfilling lives within individual capabilities. EVIDENCE: Lodge (The) DS0000013584.V273403.R01.S.doc Version 5.0 Page 13 It was evident from the available information that service users received sustained encouragement, instruction and stimulation as continuing elements of their daily lives. Life skills training opportunities were afforded service users who were supported in budgeting and managing their personal finances, thereby promoting independence. Service users had opportunity to access local support networks to facilitate integration in their local community. There was a range of information supplied to service users. Staff support enabled service users to make appropriate choices in their daily lives. Care plans indicated suitable arrangements for stimulation and involvement of service users in accordance with individual preferences, in community events and educational and vocational activities. Service users informed the inspector of their choice of arrangements for Christmas day which was spent as a group outside the home. They had evidently enjoyed a varied programme of festive activities facilitated by staff and family members, over recent weeks. One service user had spent Christmas with his family. Observations confirmed arrangements for supporting service users to maintain family links and friendships inside and outside of the home. Lodge (The) DS0000013584.V273403.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) 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. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20. Access to treatment and support from health care agencies was demonstrated. Attention was required to the management of seizures for one service user and administration and management of medication for prolonged seizures for this individual. Otherwise systems for the safe management of medication were satisfactory. EVIDENCE: Arrangements were in place for individual’s with complex health needs and behaviours to receive specialist interventions and services as required. A clear protocol was required to be in place for the management of prolonged seizures for a named service user. Further clarification was required from the medical practitioner and epilepsy specialist regarding the dose to be Lodge (The) DS0000013584.V273403.R01.S.doc Version 5.0 Page 15 administered of a new drug prescribed for this individual in the event of prolonged seizures. This must be clearly specified in the protocol to be developed and if a second dose is to be administered, explicit instructions must be in place describing in what circumstances and timescale between each dose. The manager should also discuss with the pharmacist the need for the label of this drug to record fully the medical practitioner’s instructions for this variable dose medication. A medication administration record for this drug must also be implemented. The manager must ensure that day services staff for this individual is in receipt of a copy of the protocol for administration of this medication. Observations identified that need for staff responsible for medication administration to be instructed in how to administer this drug. Lodge (The) DS0000013584.V273403.R01.S.doc Version 5.0 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16, 18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 16, 18 and 35 (Older People) 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 The complaint procedure was in a format accessible to service users and contained in the Service User Guide. Service users were familiar with the home’s complaint procedure. EVIDENCE: It was positive to observe that the service users had a complaint procedure available in an accessible format. Minutes of service users and staff meetings, complaint and communication records confirmed operation of a robust complaint procedure. Service users informed the inspector that staff listened to and acted on any concerns drawn to their attention. Lodge (The) DS0000013584.V273403.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected on this occasion however all areas viewed were observed to be clean and tidy, warm and comfortable. At the time of the last inspection the home met each of these standards providing accommodation appropriate to the needs of the current service users. EVIDENCE: Lodge (The) DS0000013584.V273403.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) 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. The home’s staffing arrangements offered flexible levels of support as necessary to meet the home’s stated purpose and service users’ needs. Staff recruitment procedures and personnel records continue to require attention. Staff on duty appeared enthusiastic and committed to supporting service users and to their personal training and development needs. The manager reported plans for reviewing the training and development programme. EVIDENCE: Staff on duty were observed to be caring and professional in their approach to service users. Individual service users informed the inspector that staff were “good” and “look after us”. Interaction between staff and individual service users demonstrated good rapport and evidenced that positive relationships existed between individual staff and service users. Lodge (The) DS0000013584.V273403.R01.S.doc Version 5.0 Page 19 Support workers had generic roles and were responsible for ancillary duties in addition to responsibilities for personal care and support also their key –worker role. Staffing levels appeared adequate. An additional two support workers had been recruited and had taken up post since the last inspection. There had been no staff turnover since that time. Observation of personnel records confirmed recruitment documentation was incomplete on both files for the new support workers. It was not evident that pre-employment information contained a full employment history or statement of mental and physical ‘fitness’. It is acknowledged that existing staff were to be shortly requested to sign a written health declaration. On the basis of information available it was evident that at least one of the two new support workers had taken up post prior to receipt of a CRB Disclosure. A comprehensive record of CRB Disclosures was not held and it was not possible to establish if POVA/First checks had been carried out for these staff prior to taking up post. Discussed was the need for the manager to establish this information from Head Office prior to staff taking up post. Staff recruited on the basis of a POVA/First check must work under supervision at all times in the delivery of personal care until a CRB Disclosure is received. Staff are not permitted to work at the home without confirmation of a POVA/First check in the event of a CRB Disclosure not being obtained. Evidence of a POVA/First check must be maintained on the personnel records held in the home, available for inspection. The manager was aware that CRB Disclosures are no longer portable. Staff received induction and core training within their six months probationary period wherever possible. The induction and core training under the Learning Disability Framework (LDAF), which was supposed to be undertaken within this period, was difficult at times to access. This could lead to probationary periods being extended. On – site LDAF training was delivered for the whole team earlier this year. Staff confirmed moving and handling refresher training had taken place since the last inspection. The manager confirmed that she intended to carry out a training needs analysis for her team to ensure all training and development core training was in place. Lodge (The) DS0000013584.V273403.R01.S.doc Version 5.0 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. Service users live in a home which is run and managed by a person who is fit to be in charge of good character and able to discharge his or her responsibilities fully. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) 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 homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) 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 Overall the management of this home was considered satisfactory. Improvement was necessary however in areas of the home’s operation and management, specifically relating to elements of health care, medication practices, record keeping and staff recruitment procedures. EVIDENCE: Lodge (The) DS0000013584.V273403.R01.S.doc Version 5.0 Page 21 The home manager had relevant knowledge, skills and experience and was registered by the Commission. She also held a management qualification and was currently studying for the Registered Manager in Care Award, NVQ Level4. Observations concluded that the home was overall being managed effectively and efficiently, promoting good practice and users rights. Attention was required to the management of epileptic seizures and related medication practices and to on-call procedures to ensure these were followed in response to incidents. The management ethos was observed to create an inclusive atmosphere. There had been relatively recent changes within the organisation’s management structure and to line management responsibilities. A Team Leader had carried out a statutory monthly provider visits on 5th December 2005. The one prior to this was on 14th July 2005. The manager advised that it was intended to in future carry out these visits on a monthly basis in accordance with statutory requirements. Records viewed were organised and satisfactorily recorded overall. Attention was required to medication records and seizure protocols for a named service user however. Security of records was demonstrated and staff were aware of the boundaries of confidentiality. 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 service users were invited to attend. Observations confirmed that in general adequate attention was given to safety and maintenance of the premises and to safe care practice. Areas of discussion included the need to further develop the home’s fire risk assessment and ensure the frequency of fire practices was in accordance with the organisation’s own policies. Lodge (The) DS0000013584.V273403.R01.S.doc Version 5.0 Page 22 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. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 x 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES CONCERNS AND COMPLAINTS Standard No Score 22 3 23 x ENVIRONMENT Standard No Score 24 x 25 x 26 x 27 x 28 x 29 x 30 x STAFFING Standard No Score 31 x 32 2 33 3 34 2 35 3 36 x CONDUCT AND MANAGEMENT 37 3 38 3 39 2 40 3 41 2 42 2 43 x Standard No 6 7 8 9 10 LIFESTYLES 11 12 13 14 15 16 17 Score 2 3 3 3 x 3 3 3 3 3 3 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x 2 3 x Lodge (The) DS0000013584.V273403.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? 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 Regulation Requirement Timescale for action 04/01/06 YA41YA19YA6YA 12(1)(a), 6, 19, 41 13(4)(c) 2 YA32YA20YA 20, 32 3 YA34YA 34 For a protocol to be developed for the management of prolonged seizures for a named service user following clarification of medical instructions for administration of medication in such circumstances. The manager must ensure this protocol is discussed with the day services attended by this individual. 13(2), For the manager to ensure 04/01/06 18(1)(c)(i) clarity of instructions for administration of variable dose medication for a named service user for use in response to prolonged seizures. Explicit instructions for administration must be detailed on the medication administration record and on the relevant seizure protocol and on the medication label. Staff must be trained in the administration of this drug. 19(1) For new staff not to take up 04/01/06 post in advance of receipt of DS0000013584.V273403.R01.S.doc Version 5.0 Page 24 Lodge (The) 4. YA34YA34 17 Sch2.7 5. YA34YA 34 17 Sch2.8 a CRB Disclosure unless a POVA/First check has been carried out. Evidence of this must be held on personnel records in the home. Staff taking up post on this basis are required to be directly supervised when carrying out personal care duties until receipt of their CR Disclosure. For a record of CRB 14/01/06 Disclosures to be available for inspection for the staff team. Brought forward from the last inspection report. Time scale for compliance unmet. For the staff recruitment 14/01/06 documentation held in the home to evidence a statement by staff of their mental and physical health ‘fitness’. Brought forward from the last inspection report. Time scale for compliance unmet. For personnel files held in 14/01/06 the home to include a full employment history also documentary proof of identity including a recent photograph. Brought forward from the last inspection report. Timescale for compliance unmet. For statutory visits to be undertaken unannounced by an employee of the organisation at least once a month in accordance with Regulation 26. (4)(a)(b)(c) of the Care Homes Regulations. Brought forward from the last 31/01/06 6. YA34 17 Sch2.6 7. YA39YA 39 26 (2)(4)(c) Lodge (The) DS0000013584.V273403.R01.S.doc Version 5.0 Page 25 inspection report, timescale for compliance un met. 8. YA42YA 42 23(4)(c) For the frequency of fire practices to be increased. 14/01/06 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. Refer to Standard YA42 Good Practice Recommendations To review and further develop the fire risk assessment. Lodge (The) DS0000013584.V273403.R01.S.doc Version 5.0 Page 26 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. Extracts may not be used or reproduced without the express permission of CSCI. Lodge (The) DS0000013584.V273403.R01.S.doc Version 5.0 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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