CARE HOME ADULTS 18-65
Mere Lodge 93 Mere Road Leicester LE5 5GQ Lead Inspector
Keith Williamson Unannounced Inspection 4th November 2005 11:30 Mere Lodge DS0000064385.V258495.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 Mere Lodge DS0000064385.V258495.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 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. Mere Lodge DS0000064385.V258495.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Mere Lodge Address 93 Mere Road Leicester LE5 5GQ 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) 01628 826944 Mere Lodge Healthcare Ltd Miss Tracy Jayne Johnson Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Mere Lodge DS0000064385.V258495.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 18th July 2005 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 DS0000064385.V258495.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The focus of the inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service users and their views of the service provided. The primary method of Inspection used was ‘case tracking’ which involves selecting clients and tracking the care they received through looking at their records, talking with them where possible, and looking at their accommodation. What the service does well: What has improved since the last inspection? What they could do better:
Staff could be signed up for the accredited medication administration course. All “as required” or prn medications could be risk assessed and accurate instruction be given to the staff, of precisely how and when the medication should be given. The updated Protection of Vulnerable Adults guidance has yet to be obtained, and shared with the staff group. Monitoring of the home by the Responsible Individual could be reported to the commission for social care inspection by the commencement of sending the appropriate reports. Mere Lodge DS0000064385.V258495.R01.S.doc Version 5.0 Page 6 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 DS0000064385.V258495.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Mere Lodge DS0000064385.V258495.R01.S.doc Version 5.0 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 the following standard(s): None. None of these standards were viewed on this occasion. EVIDENCE: Mere Lodge DS0000064385.V258495.R01.S.doc Version 5.0 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 the following 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 the residents’ care plans indicated that aspects of their assessed care needs have been identified and recorded on the document which is reviewed on a regular basis. The manager has commenced the implementation of the person centred plans for residents in the home; these are being produced in way that can be interpreted by the residents in the home. Advocacy assistance is being arranged for at least one of the residents. Residents are offered positive life choices both within and outside the home, these appear to be made on a spontaneous basis. This has resulted in the residents’ expectations of one on one time being used effectively, it is expected that the current staffing ratio remains high to ensure the resident contact continues.
Mere Lodge DS0000064385.V258495.R01.S.doc Version 5.0 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 the following standard(s): 12 & 15. Good opportunities are provided for residents to participate in activities. Residents have the opportunity to continue personal relationships in the home. EVIDENCE: Residents are able to engage in culturally appropriate activities. Though these are arranged in advance residents have the opportunity to amend arrangements at the last moment as the current staffing allows for individual intervention. Visiting to the home is unrestricted, residents being encouraged to keep up family relationships. Mere Lodge DS0000064385.V258495.R01.S.doc Version 5.0 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 the following standard(s): None. None of these standards were viewed on this occasion. EVIDENCE: Mere Lodge DS0000064385.V258495.R01.S.doc Version 5.0 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 the following standard(s): 22 & 23. Robust processes are in place so that residents or their relatives can make complaints and adult protection procedures protect residents from all forms of abuse. EVIDENCE: Examination of the written complaint process indicated that clear guidance is given to residents and their relatives on how to make a complaint. There has been one complaint received by the home, this was investigated and responded to, within the homes’ own guidance and time limits; there have been no complaints forwarded directly to the Commission for Social Care Inspection. The adult protection process was inspected. Clear guidance is written in the adult protection policy on how to avoid the risk of vulnerable adult abuse. No residents spoken with, could express their interpretation of either of the above the policies. Mere Lodge DS0000064385.V258495.R01.S.doc Version 5.0 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 the following standard(s): None. None of these standards were viewed on this occasion. EVIDENCE: Mere Lodge DS0000064385.V258495.R01.S.doc Version 5.0 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 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): 35. Residents benefit form a well trained and effective staff group. EVIDENCE: Evidence is apparent of the courses offered to the staff in the home. A balance of “in house” and “external” trainers are used to accomplish this, courses are planned and arranged individually following supervision and appraisal sessions. Individual certificates of attendance are in evidence in staff files. Mere Lodge DS0000064385.V258495.R01.S.doc Version 5.0 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 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): 39. Residents and their representatives are consulted and involved in the running of the home, this forms a sense of inclusion for the group. EVIDENCE: Short term but effective quality monitoring systems are in place in the home. Quality assurance questionnaires are planned and shall be issued periodically to a range of individuals who visit and support the home; the manager indicated the outcomes of these will be added to the review of the Statement of Purpose and Service User Guide following the initial release of the forms. The business plan for the home is now in place, though regulation 26 reports of visits by the Responsible Individual have yet to commence on a regular basis, this would ensure the inspector was aware of the support the manager is receiving for his newly opened home. Mere Lodge DS0000064385.V258495.R01.S.doc Version 5.0 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 X X X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 X Standard No 24 25 26 27 28 29 30
STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X X X X 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Mere Lodge Score X X X X Standard No 37 38 39 40 41 42 43 Score X X 3 X X X X DS0000064385.V258495.R01.S.doc Version 5.0 Page 17 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. Standard Regulation Requirement Timescale for action 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 Refer to Standard YA6 YA20 Good Practice Recommendations It is recommended that person centred planning (pcps) be introduced for all residents living in the home, and the key workers are involved in the compilation of those plans. It is strongly recommended that all “as required” or prn medications are risk assessed and accurate instruction be given to the staff, of precisely how and when the medication should be given. (This was recommended at last Inspection 18th July) It is strongly recommended that all staff be signed up for the accredited medication administration course. (This was recommended at last Inspection 18th July) It is recommended that the manager obtain the updated protection of Vulnerable Adults guidance and shares with the current resident and staff group. It is strongly recommended that monitoring of the home by the Responsible Individual is reported to the commission for social care inspection by the commencement of sending the appropriate reports.
DS0000064385.V258495.R01.S.doc Version 5.0 Page 18 3 4 5 YA20 YA23 YA38 Mere Lodge Commission for Social Care Inspection Leicester Office 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 DS0000064385.V258495.R01.S.doc Version 5.0 Page 19 - 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!
