Inspection on 18/07/05 for Mere Lodge

This inspection was carried out on 18th July 2005.

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

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

Other inspections for this house

Mere Lodge 15/07/08

Mere Lodge 16/07/07

Mere Lodge 30/05/06

Mere Lodge 04/11/05

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Mere Lodge 93 Mere Road Leicester LE5 5GQ Lead Inspector Keith Williamson Unannounced 18 July 2005 at 9.45 am 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 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 Stationary 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. Mere Lodge C51 C01 S64385 Mere Lodge V238405 180705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Mere Lodge Address 93 Mere Road Leicester LE5 5GQ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0116 2517441 None Mere Lodge Healthcare Ltd Miss Tracy Johnson Care Home 4 Category(ies) of LD Learning Disability - 4 registration, with number of places Mere Lodge C51 C01 S64385 Mere Lodge V238405 180705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: There are no additional conditions of registration. Date of last inspection N/A Brief Description of the Service: Mere Lodge is a converted 2 storey, 4 bedded terraced property in the Highfields area of the city of Leicester. It is situated adjacant to Spinney Hill park and close to many shops and local amenities. The home consists of 2 lounges, a dining kitchen, and large bathroom with whirlpool bath to the ground floor; all 4 bedrooms, toilet with shower enclosure, and office are on the first floor; access to which is by the main staircase. Mere Lodge C51 C01 S64385 Mere Lodge V238405 180705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over one day, commenced at 9.00 am and was completed in four hours by one Inspector. An opportunity was taken to view the care plans and other records in detail. Two residents were in the home at the commencement of this inspection, neither resident elected to speak with the inspector, therefore no residents’ or their relatives were spoken with on this visit; nor any comment cards have yet been returned. The manager assisted with the Inspection, spending time with the Inspector discussing the management of the home. This is the first inspection visit to this home and overall the inspector recognised the home functions fairly well and provides a homely but secure environment for residents’. What the service does well: What has improved since the last inspection? What they could do better: There are a number of policies that have been developed for the home, some of these have not yet been copied into the policies and procedures file. The registered person must adhere to the registration categories when admitting residents into the home. The home could develop the policy for residents to self-administer medication. Mere Lodge C51 C01 S64385 Mere Lodge V238405 180705 Stage 4.doc Version 1.40 Page 6 The present resident group did not wish to be interviewed as part of the inspection process, to this end the development of questionnaires for residents or their representative would be an advantage in learning the comments of residents and their supporters on the home. The involvement of advocacy services would also assist to that end. The manager should develop the policies and procedures in the home, with a view to having copies of these held appropriately in the home. 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. Mere Lodge C51 C01 S64385 Mere Lodge V238405 180705 Stage 4.doc Version 1.40 Page 7 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 Standards Statutory Requirements Identified During the Inspection Mere Lodge C51 C01 S64385 Mere Lodge V238405 180705 Stage 4.doc Version 1.40 Page 8 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 standard(s) 1, 2, 3 & 5. The admission process is good. There is detailed information about the type of service provided in the home, which is available for prospective residents and their relatives. The assessment process is very detailed and effective. EVIDENCE: Careful examination of the Statement of Purpose indicated that it accurately outlines the services provided in the home. Three residents’ assessments and admission records were viewed, these indicated that the admission process is secure and detailed, and a contract of residence is then provided outlining the Terms and Conditions of their residency in the home Mere Lodge C51 C01 S64385 Mere Lodge V238405 180705 Stage 4.doc Version 1.40 Page 9 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 standard(s) 6, 7 & 9. Residents’ care plans are written in great detail. Robust processes are in place to give residents the independence to make safe decisions with good risk management in place. EVIDENCE: Detailed inspection of three residents’ care plans indicated that all aspects of their assessed care needs have been identified and recorded on the document which is reviewed on a regular basis. All care plans and risk assessments seen including detailed discussion with the registered manager indicated that the care plans have good information in setting out the actions staff members must take to meet all residents’ assessed care needs. Mere Lodge C51 C01 S64385 Mere Lodge V238405 180705 Stage 4.doc Version 1.40 Page 10 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 standard(s) 11, 12, 13, 14, 16 & 17. Good opportunities are provided for residents to access leisure facilities. Residents maintain good community links and have satisfactory choice concerning their daily lives including eating well balanced meals. EVIDENCE: No residents are currently in employment, due to the complex nature of the current residents’ needs. Residents’ plans of care include elements adapted from care plans developed within a multi disciplinary setting, and include many positive aspects of their current abilities. Two residents daily records were seen, these indicated that their daily routine includes regular contact with relatives and friends. Discussion held with the registered manager indicated that meals are varied and wholesome and given to the residents according to their choice, for example on the day of the inspection both residents elected to go to a local restaurant for lunch. Mere Lodge C51 C01 S64385 Mere Lodge V238405 180705 Stage 4.doc Version 1.40 Page 11 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 standard(s) 18, 19 & 20. Suitable processes are in place to meet residents’ hygiene and health care needs. The medication process works well in ensuring that residents receive correct doses of medication. EVIDENCE: The manager indicated that support is given by the staff to ensure that residents personal hygiene and associated care needs are fully met, which is recorded in all residents’ care plans and their daily care records. Detailed inspection of three residents’ care records indicated that healthcare professionals such as Community Nurses, General Practitioners and the multi disciplinary team form part of the care process. The manager indicated that that resident’s access doctors and other professionals located in the community as part of their ongoing care. Discussion held with the registered manager indicated that residents do not yet administer their own medication. The medication policy seen contains sufficient information for staff members’ guidance regarding monitoring residents when they take their own medication, but has yet to be developed to include residents self administration of medication. Robust risk assessments were seen for the protection of both residents. Mere Lodge C51 C01 S64385 Mere Lodge V238405 180705 Stage 4.doc Version 1.40 Page 12 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 standard(s) None EVIDENCE: These standards shall be assessed on the second inspection later in 2005/06. Mere Lodge C51 C01 S64385 Mere Lodge V238405 180705 Stage 4.doc Version 1.40 Page 13 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 standard(s) 24, 28 & 30. The home is maintained to a very high standard. Adequate communal space is provided in the home for residents’ comfort. The home is clean, hygienic and pleasant in appearance, which creates a homely environment. EVIDENCE: An inspection of the carpets, walls and fixtures throughout the home indicated that the premise is being maintained in good condition. The manager indicated she feels satisfied with the communal facilities, which provides adequate space large enough for residents’ leisure activities. An inspection of the premise indicated that it is clean and hygienic in appearance. Mere Lodge C51 C01 S64385 Mere Lodge V238405 180705 Stage 4.doc Version 1.40 Page 14 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 The care hours provided is sufficient to provide suitable care and protection for residents on a daily basis. EVIDENCE: A calculation of staffing hours using the Residential Forum for Younger Adults indicated that the staffing rota was adequate to meet the current group of residents. The rota is designed to provide a minimum of one to one working with residents in the home on a daily basis. Evidence is currently in place of a high degree of intervention in respect of social and cultural needs. Mere Lodge C51 C01 S64385 Mere Lodge V238405 180705 Stage 4.doc Version 1.40 Page 15 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 40, 41 and 42. The procedures and written policies seen are satisfactory in providing good guidance for staff members. Good record keeping is maintained in the home to ensure safety and privacy. EVIDENCE: A number of written documents were inspected, namely the medication, infection control, complaints and adult protection policies staff members on duty displayed verbal knowledge concerning the content of the policies. Examination of the care records, care plans and daily records indicated that records are being kept in accordance with the Data Protection Act 1998 and the Care Homes Regulations 2001. A copy of the recorded visits by the registered individual to the home are produced but as yet not forwarded appropriately to the inspector. Mere Lodge C51 C01 S64385 Mere Lodge V238405 180705 Stage 4.doc Version 1.40 Page 16 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 2 x 3 Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x 3 x 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 x 3 3 Standard No 31 32 33 34 35 36 Score x x 3 x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Mere Lodge Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x x x 3 3 2 x C51 C01 S64385 Mere Lodge V238405 180705 Stage 4.doc Version 1.40 Page 17 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 3 Regulation 14 (1) Requirement The registered person must only admit residents covered by the current categories stated in the registration certificate of the home. The registered person must ensure the water temperature to the ground floor bath is regulated to the recommended level to prevent scalding. The registered person must ensure that staff are appropriately trained in fire evacuation, and regular fire drills be held in the home, and accurate records kept of these events. Timescale for action by 1st August 2005. 2. 42 12 (1) a by 1st August 2005. by 1st August 2005. 3. 42 23 (4) c, d, & e 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 6 Good Practice Recommendations It is recommended that each of the three shifts be encouraged to give accurate reports on the welfare of residents, on a daily basis. C51 C01 S64385 Mere Lodge V238405 180705 Stage 4.doc Version 1.40 Page 18 Mere Lodge 2. 3. 4. 5. 6 6 20 20 6. 7. 8. 20 20 20 It is recommended that person centred planning (pcps) be introduced for all residents living in the home, and the key workers be involved in the compilation of those plans. It is recommended that a daily living plan be introduced for each resident in the home, this would enable staff to follow and refer to the care plan more easily. It is recommended that a General Practitioner be involved in the setting up of, and then signing of, the homely remedy policy and procedure. It is strongly recommended that all occasionally prn medications be risk assessed and accurate instruction be given to the staff, of precisely how and when the medication should be given. It is strongly recommended that resident photographs be included in the medication administration (mar) system. It is strongly recommended that all medications are recorded when received into the home. It is strongly recommended that all staff be signed up for the accredited medication administration course. Mere Lodge C51 C01 S64385 Mere Lodge V238405 180705 Stage 4.doc Version 1.40 Page 19 Commission for Social Care Inspection The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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 Mere Lodge C51 C01 S64385 Mere Lodge V238405 180705 Stage 4.doc Version 1.40 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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