Inspection on 30/08/06 for The Lodge

This inspection was carried out on 30th August 2006.

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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Lodge 12/01/10

The Lodge 19/02/09

The Lodge 17/09/07

The Lodge 29/06/05

The Lodge 08/12/04

The Lodge 24/08/04

The Lodge 01/03/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Lodge, The Bridge End Eldersfield Gloucestershire GL19 4PN Lead Inspector Dianne Thompson Unannounced Inspection 30 August and 10 September 2006 14:00 th th Lodge, The DS0000018687.V309729.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 DS0000018687.V309729.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 DS0000018687.V309729.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lodge, The Address Bridge End Eldersfield Gloucestershire GL19 4PN 01452 840088 01452 840088 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) Glevum Farm Trust Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Lodge, The DS0000018687.V309729.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home may accommodate one named person with a learning disability who is over the age of 65. The home may accommodate one named person who has an additional physical disability. 5.10.2005 Date of last inspection Brief Description of the Service: The Lodge provides residential accommodation for a maximum of six adults, one of whom is over the age of 65, who have learning disabilities. The home is located in Eldersfield and forms part of a working farm. The farm is staffed separately from the residential accommodation and offers day activities in farming and horticulture to individuals from the surrounding communities. The day activities of residents who live in the home are not limited to the onsite facilities and are developed in a way that reflects individual interests outside the farm environment. Glevum Farm Trust owns the property. The trustees are registered as providers and as such carry responsibilities for the overall development and management of the home. Mr E Davies is identified as the Trust Manager, Company Secretary and Responsible Individual. The home currently has an acting manager. The Glevum Farm Trust operates another establishment in New Street, Ledbury, Herefordshire, which is included in the registration as an annexe of the Lodge. The fee levels for The Lodge will be provided for inclusion in the final report. Lodge, The DS0000018687.V309729.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection that included an unannounced visit to The Lodge. A second visit was arranged so the acting manager could be available to discuss the development of the service. The main purpose of this inspection was to assess the service provided against key National Minimum Standards. Service user and staff records were examined, and a tour of the building was also carried out. Accumulated evidence from reports of monthly visits by the provider was used to inform this report. Time was spent with four residents and three staff. What the service does well: Glevum Farm Trust provides a home for people with learning disabilities, in a rural part of Gloucestershire and accommodation for people to live more independently in Ledbury, Herefordshire. Information is available about the home to help new residents decide whether they would like to live at the Lodge, and whether the home can meet their needs. Activities take place both within the home and the local community. The personal and healthcare needs are identified in individual care plans. This provides information to promote consistency of care and support for all residents. Care plans provide staff with relevant information about residents assessed needs. They include risk assessments detailing how risks are to be reduced and independence promoted. Residents are enabled to make choices and decisions in their daily lives and routines. Residents receive help and encouragement to lead active and interesting lives and are supported to access facilities within the wider community. They are also supported to maintain links with their families and to develop friendships. The home offers a well-balanced menu and promotes healthy eating for the welfare of all residents. The home has a complaints policy and procedure, which is also included in the service users guide. The home’s complaints procedure is also completed in widget signs and symbols for all residents. Residents are supported to make complaints should they wish to do so. Lodge, The DS0000018687.V309729.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: All health information should be transferred into residents’ individual files as soon as possible to ensure that confidentiality is respected. Advice should be obtained from the GP and a referral to a dietician considered to establish an action plan and agreed guidelines for support for residents with dietary difficulties. The location of the first aid box should be clearly identified in the kitchen and in the lounge/dining room. Cash tins should not be kept in the medication cabinet. Surplus medication should be kept separate from current medication to ensure appropriate stock rotation. Limited stocks of medication should be stored. A separate hard backed record book should be made available for the administration of controlled drugs should they be required. Medication storage should be improved. During the inspection, staff on duty completed the recommendations for the safe and effective storage of medication. The installation of an additional ceiling light to the lounge dining area should be considered for the benefit of staff and residents. The full time manager is no longer employed at the home and a part time acting manager, who was previously the registered manager of the home, is managing the home until a replacement manager is employed. Lodge, The DS0000018687.V309729.R01.S.doc Version 5.2 Page 7 A quality assurance audit must be completed within the home in accordance with the NMS regulations and requirements, and a report sent to the Commission for Social Care Inspection. 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 DS0000018687.V309729.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 DS0000018687.V309729.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, 5 Quality in this outcome area is good. This judgement has been made using available evidence including visits to the service. Detailed information is provided about the services offered at the home to help residents make an informed choice about whether they would like to live at The Lodge and whether the home will meet their needs. EVIDENCE: The home’s statement of purpose and service user guide provides information about the home to help prospective residents decide if they wish to live at The Lodge. Copies of this information are accessible to all and staff confirmed this would be provided to all prospective residents prior to moving into the home. The home has an admissions procedure, which would be followed with all prospective admissions to the home. A detailed assessment would be completed, and other views and information would be sought from family and other professionals. An appropriate care plan would be established using the information gathered during the assessment process. All residents have a copy of their contract together with a service user guide, which includes the terms and conditions within the home. The service user guide has been developed and includes very detailed information in written and picture format to make the document more accessible to all residents. Lodge, The DS0000018687.V309729.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is adequate. This judgement has been made using available evidence, including visits to the service. Care plans provide staff with relevant information about residents assessed needs. They include risk assessments detailing how risks are to be reduced and independence promoted. Residents are enabled to make choices and decisions in their daily lives and routines. EVIDENCE: Case tracking the files for two residents was completed. Case tracking provides a view of how the home responds to the diversity of needs and how this is being managed and supported. This is particularly evident where health needs and disability requires greater input and support from all staff within the home. Relevant information and monitoring is provided in resident’s files to make sure all staff has access to necessary information to provide quality care. The existing care plans have been reviewed regularly or as any changes in need have occurred. Staff spoken to are fully aware of the plans and use them to guide their practice. A resident said that the staff are very good and always help them to do what they want. Lodge, The DS0000018687.V309729.R01.S.doc Version 5.2 Page 11 Each resident has been allocated a client coordinator to oversee the care plan development, with time allocated for these to be completed. Person centred plans are being introduced and each resident will have all their information contained in one file instead of separate files. The current practice within the home where medical and health information for all residents is contained in one separate file will cease. A copy of the format for the person centred plans has been supplied to the Commission for Social Care Inspection (CSCI). The format includes daily routines, health, likes and dislikes, assessment of needs, goals and future plans. The home is arranging a support plan review document that enables residents to decide who they would like to be involved in their reviews. The plans are in symbols and picture format suitable for residents to understand. Life books are being completed to establish individual life histories with all residents. The home is working to new risk assessment guidelines and procedures. A copy has been supplied to the CSCI. The guidance notes provide assistance for the completion of the service user risk assessment form. All existing risk assessments will be reviewed using the new format. A risk assessment must be completed for a resident where a risk of choking has been identified, and guidelines established for action to take should choking occur. Evidence is available to demonstrate the support that has been given to residents in making their will. Lodge, The DS0000018687.V309729.R01.S.doc Version 5.2 Page 12 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): 12, 13, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence, including visits to the service. Residents receive help and encouragement to lead active and interesting lives and are supported to access facilities within the wider community. They are also supported to maintain links with their families and to develop friendships. The home offers a well-balanced menu and promotes healthy eating for the welfare of all residents. EVIDENCE: The home provides varied activities both within the home and in the local community. On the afternoon of the first inspection visit, five residents were at home having returned from working on the farm or attending day centres. The home was very active. One resident went out for the evening to a nearby town with a member of staff, and planned to go to a pub for their evening meal. Another resident was busy helping a member of staff to fold up the laundry that had been dried, and was putting away the towels. One resident said he had recently been to Weston on the train. Another resident was Lodge, The DS0000018687.V309729.R01.S.doc Version 5.2 Page 13 listening to music in the lounge. One resident said that another member of staff had given him a foot spa the night before. One resident made a cup of coffee for the inspector. Another resident was busy painting a workroom wall during the inspection, and was ‘too busy to talk’. One resident told the inspector that he goes to Tewkesbury AOC, and he also enjoys going dancing with the over 60’s on a Wednesday evening, which is due to restart. External activities encouraged at the home include rainbow club on Monday evenings, shopping in Tewkesbury, visits to Gloucester docks, and holidays. Other internal activities include ‘deconstruction’ sessions, gym activities, recycling, music and art. There was evidence that support for residents to maintain family contact has been discussed and is included in care plans. The home recently had a garden party that was well attended by people from the local community, relatives and friends. Residents are offered a healthy and nutritious diet. Menus are planned with the residents each Wednesday evening for the following week. All residents are able to contribute towards the planning, and are clearly able to make their choices known. The evening meal was being cooked during the first inspection visit. Residents and staff prepared and cooked the meal, with group singing throughout the process. It was apparent the task was an enjoyable one. One resident particularly likes custard, so he made the custard for the pudding. The inspector was invited to participate in the evening meal of liver and bacon, with potatoes, fresh vegetables and gravy. Plums and custard was offered for dessert. Alternatives were available for those people not wanting/liking what was on the menu, e.g. sausages as an alternative to liver was requested for one person and banana instead of plums with custard for another person. The meal was taken around the dining table in the kitchen, in a relaxed and comfortable manner. The residents said they enjoyed their meal. Residents helped to clear away after the evening meal, and it was evident that these are established routines, e.g. one person helped to clear the table, another person wiped the table, and another person made drinks of tea or coffee for everyone, which was taken in the lounge. Lodge, The DS0000018687.V309729.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is adequate. This judgement has been made using available evidence, including visits to the service. Personal and healthcare needs are identified in care plans. The plans provide information and promote consistency of care and support for all residents in a way that takes into account their preferences. The home has a medication policy and procedure, which is followed to make sure that all medication is administered and stored safely for the protection of residents and staff. EVIDENCE: Residents care records and plans provide information about their physical and mental health and the support needed from staff to maintain their good hygiene and health. The care plans sampled contained information about residents preferred personal care routines. One member of staff talked about introducing aromatherapy sessions to the residents, with their agreement. One resident showed his new glasses that he had collected from the optician on that day. Lodge, The DS0000018687.V309729.R01.S.doc Version 5.2 Page 15 Residents and the home are well supported by medical services, which includes GP’s, dentist, community learning disability team, and occupational health. Medical and health information and records for all residents are contained in one file. All information should be transferred into residents’ individual files as soon as possible to ensure that confidentiality is respected. The home is developing a person centred planning approach and staff said that medical and health information would be transferred as part of this development. Well person checks are currently being completed for all residents in the home. One member of staff said that they had responsibility to oversee this and make sure everyone had the opportunity for a full medical check. Health concerns involving the diet for one resident was discussed. Advice should be obtained from the GP and possibly a referral to a dietician to establish an action plan and agreed guidelines for support. The medication cabinet is stored inside a securely locked cupboard that has been installed in the lounge/dining room. At the time of the inspection the first aid kit was stored in this cupboard, but was relocated by staff following a discussion about accessibility. The location of the first aid box should be clearly identified in the kitchen and in the lounge/dining room. The contents of the medication cabinet were checked. The cabinet has an inner locked cabinet which is suitable for storage of controlled drugs should they be necessary. This inner cabinet should be kept free for controlled drugs. Additionally, a separate hard backed record book should be made available for the administration of controlled drugs should they be required. It is important that the medication cabinet is kept tidy to minimise errors with medication administration and promote effective stock rotation. Resident’s medication should be appropriately stored in individually labelled containers. Cash tins should not be kept in the medication cabinet. Surplus medication should be kept separate from current medication to ensure appropriate stock rotation. Additionally only limited stocks of medication should be stored. A bottle of Cough syrup should not be available for general use. Specific cough syrup should be obtained for each resident as required, preferably in consultation with his GP. The name of the resident and the date of opening should be recorded on each bottle. Paracetamol should not be available for general use. As with cough syrup all medicines should be identified for individual residents use only, and if necessary individual packs of medication including paracetamol should be obtained. All paracetamol administered should be recorded on appropriate medication record sheet (MAR). Paracetamol administration is recorded on Lodge, The DS0000018687.V309729.R01.S.doc Version 5.2 Page 16 individual daily record sheets but this does not comply with acceptable medication practice and procedures, nor does it allow for effective monitoring or recording of administration. Staff on duty at the time of the inspection visit addressed the medication storage and labelling issues during the inspection. Lodge, The DS0000018687.V309729.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 adequate. This judgement has been made using available evidence including a visit to this service. Residents are given the support they need to raise any concerns they may have. EVIDENCE: The home has a complaints policy and procedure, which is also included in the service users guide and the home’s policies folder. Information is provided for people to know how to complain and to whom, and also includes reference to the CSCI. No complaints have been received by the home or CSCI since the last inspection. The home’s complaints procedure is also completed in widget signs and symbols for all residents. Time was spent with residents in the lounge and the kitchen/dining area. Residents said staff support them when they need it and they feel able to ask for help or can talk to staff if they have any concerns. The inspector spoke with staff and residents about the home’s complaints and protection policies and procedure. Two residents said they would know how to complain if they were not happy, and they would tell staff and or the home manager. They also confirmed they have a copy of the procedure. During the inspection visits staff were observed engaging with residents in a supportive and respectful way. The acting manager said that a date for staff training in abuse awareness is being organised through ‘interact’ training company. This training is to be delivered at the home to enable all staff to attend. Lodge, The DS0000018687.V309729.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, 25, 26, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Lodge is located in Eldersfield and forms part of a working farm. home is comfortable, clean and hygienic. EVIDENCE: The lodge is a detached home, which has a large lounge/dining room, a separate smaller lounge, kitchen with dining table, and sufficient bathroom, shower and toilets to accommodate the needs of residents. The home has been improved since the previous inspection visit and is now refreshed and appears more homely. A tour of the home was completed, with two residents showing their rooms to the inspector. All residents have single bedrooms that are individually furnished and promote their interests and their independence. Consideration should be given to the use of the vacant bedroom and whether this room should be occupied under the present arrangement, as the room is small with a sloping ceiling, and does not meet the NMS room size. One resident said he was having his room redecorated – ‘a change of colour from the blue which is a bit dark to something lighter – maybe yellow’. Lodge, The DS0000018687.V309729.R01.S.doc Version 5.2 Page 19 The The downstairs shower room and toilet is due to be repaired and repainted. Windows have been replaced throughout the home, and are a pleasing improvement to the appearance, the security and the condition of the home. A secure cupboard has been installed in the lounge/dining room where records, medication and finance are stored securely. All staff now have identity badges, which was evident during the visits. The residents have adopted a cat called Lucy, who appears settled and comfortable in the home. New curtains have been fitted to the lounge. An additional ceiling light in the lounge would be beneficial, especially for completing records and paperwork during the evenings. Staff at the home have requested new lounge furniture, as the sofa is not very comfortable. The range is not in working order in the kitchen, but a separate cooker is installed. The Responsible Individual said there are plans to replace the range at some time in the future, but consider this to be low priority at the moment. It is also the home’s policy not to install a dishwasher, as the kitchen activities are very central to the home’s lifestyle. The home is now ‘non-smoking’ and this has significantly improved the home environment. A new carpet has been fitted and a telephone installed in the flat in New Street. The shower has also been rebuilt. This meets the requirement from the previous inspection. Lodge, The DS0000018687.V309729.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): 32, 34, 35, 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staff and residents understand the roles and the responsibilities of the care staff. The home’s recruitment policy and practices make sure that suitable staff are employed and that all necessary checks are made to ensure the safety of all residents. EVIDENCE: Staff on duty at the time of the inspection visits spoke of the positive relationship within the staff team, and that everyone worked well together. The staff, the Responsible Individual (RI) and the acting manager all spoke of the improved morale within the staff team and the effect on the residents. The atmosphere within the home appears to be more relaxed, with the residents and staff happier and more at ease within in the home environment. A recently appointed member of staff was interviewed during the inspection visit. He confirmed that all the appropriate checks had been made prior to his commencement at the home. A copy of his enhanced CRB check was seen. Introductory visits to the home and an interview with the RI and a Trustee was conducted. The member of staff confirmed this. Lodge, The DS0000018687.V309729.R01.S.doc Version 5.2 Page 21 Induction has included shadowing regular members of staff. Training courses have been arranged in Health and Safety, Food Hygiene, and First Aid appointed person. Manual handling training is being arranged for September or October 2006. The new employee said that he was enjoying his job, ‘the work is different’ to what he was doing before and that he ‘feels some satisfaction’ with his work. He feels he has a good rapport with the residents and this was evident in how relaxed and comfortable the residents seemed in his company. Training is being arranged for all staff, and this was seen on the training plan. Some staff felt they would find risk assessment training beneficial (see section ‘conduct and management of the home’). The acting manager confirmed that a staff handbook is being developed which will include the ‘Scils for Care’ induction course and individual staff training and development plans. A copy of this handbook is to be sent to CSCI. While mandatory training courses are being completed, staff were unable to confirm that NVQ training is taking place. The acting manager and RI said they are not able to address this situation at the moment as a full evaluation of staff training needs to establish the training and development programme is being completed. The home must ensure that the training and development programme for all staff incorporates NVQ’s as required. A copy of this programme should be submitted to CSCI. Staff supervision is to be arranged by the acting manager, who has also introduced a new supervision format. A copy has been supplied to CSCI. The acting manager is aware that improvements in the regularity of staff supervision will be needed to meet the required 6 sessions per year. Staff said that regular staff meetings are held and evidence was seen in the staff meeting minutes of 24/8/06. Lodge, The DS0000018687.V309729.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, 39, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The health and safety of the residents is protected and risk assessments are completed which aim to minimise risks and promote independence. EVIDENCE: The staff seen during the inspection visits appeared relaxed and confident in their work, and their environment. Staff said they feel supported to be able to do their work and to use their initiative. There have been significant changes within the staff team since the previous inspection. The full time manager has left and a part time acting manager, who was previously the registered manager of the home, is managing the home. The RI supports this arrangement, until a new manager is appointed. Additional staff have been recruited and staffing levels have improved as a consequence. The acting manager has introduced new systems to the home, Lodge, The DS0000018687.V309729.R01.S.doc Version 5.2 Page 23 e.g. care plans, risk assessments and supervision format, all of which will be beneficial when fully implemented. Quality monitoring reports (reg.26) had not been received by CSCI prior to the inspection visit. Copies were available at the home and were supplied to the inspector. An additional sample format for monthly reports has been provided for the RI by the inspector. A quality assurance audit must be completed within the home in accordance with the requirements of Regulation 24 and Standard 39. The views of staff, family, friends and advocates, and of stakeholders in the community should be sought to say how they feel the home is achieving goals for residents. The results of resident’s and other surveys should be published. A report should be compiled and a copy sent to CSCI and details of residents’ views should be included in the Service User Guide. Health and safety aspects are being managed within the home, with staff taking responsibility for aspects of safety. Staff indicated that risk assessment training would be beneficial, in improving their understanding of how risks are to be fully assessed and reduced/eliminated. Windows have been replaced throughout the home since the previous inspection. The accident book was seen. The book is kept in the cupboard and is accessible. Completed accident records are stored in a locked file in the main office and comply with the Data Protection Act. Coshh materials are appropriately stored in locked storage areas. Lodge, The DS0000018687.V309729.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 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 X 2 X X 3 2 Lodge, The DS0000018687.V309729.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. YA9 Standard Regulation 13 (4) Timescale for action A risk assessment must be 20/10/06 completed for a resident where a risk of choking has been identified, and guidelines established of action to take should choking occur. Cough syrup and Paracetamol should not be available for general use. The name of the resident and the date of opening should be recorded on each bottle. All medication administered should be recorded on the appropriate medication record sheet (MAR) and should include over the counter and PRN (when required) medication. The home must ensure that there is a training and development programme for all staff that incorporates NVQ’s as required. A copy of this programme should be submitted to CSCI. 20/10/06 Requirement 2. YA20 13 (2) 3. YA20 13 (2) 20/10/06 4. YA35 18 20/11/06 Lodge, The DS0000018687.V309729.R01.S.doc Version 5.2 Page 26 5. YA39 24 A quality assurance audit must be completed within the home in accordance with the NMS regulations and requirements. 30/11/06 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. 4. 5. 6. 7. 8. Refer to Standard YA19 YA19 YA20 YA20 YA20 YA20 YA20 YA42 Good Practice Recommendations All health information should be transferred into residents’ individual files as soon as possible to ensure that confidentiality is respected. Advice should be obtained from the GP and a referral to a dietician considered to establish an action plan and agreed guidelines for support for residents with dietary difficulties. The location of the first aid box should be clearly identified in the kitchen and in the lounge/dining room. A separate hard backed record book should be made available for the administration of controlled drugs should they be required. The medication cabinet should be kept tidy at all times, to minimise errors with medication administration and promote effective stock rotation. Cash tins should not be stored in the medication cabinet. Surplus medication should be kept separate from current medication to ensure appropriate stock rotation. Limited stocks of medication should be stored. The installation of an additional ceiling light to the lounge dining area should be considered for the benefit of staff and residents. Lodge, The DS0000018687.V309729.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 DS0000018687.V309729.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!