Inspection on 14/11/06 for Mimosa Lodge

This inspection was carried out on 14th November 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mimosa Lodge 27/07/07

Mimosa Lodge 13/10/05

Mimosa Lodge 06/06/05

Mimosa Lodge 23/09/04

Mimosa Lodge 13/04/04

Mimosa Lodge 08/01/04

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Hillview Farm

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Fairways

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Kestrel House, St Anne`s Opportunity Centre,

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

CARE HOME ADULTS 18-65 Mimosa Lodge Winchester Road Botley Southampton Hants SO32 2DH Lead Inspector Craig Willis Unannounced Inspection 14th November 2006 10:45 Mimosa Lodge DS0000052790.V315590.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 Mimosa Lodge DS0000052790.V315590.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. Mimosa Lodge DS0000052790.V315590.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mimosa Lodge Address Winchester Road Botley Southampton Hants SO32 2DH 01420 564028 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) ILIACE Limited To Be Confirmed Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Mimosa Lodge DS0000052790.V315590.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th October 2005 Brief Description of the Service: Mimosa Lodge is registered to provide care and accommodation to seven people with learning disabilities. Service users are provided with their own bedroom and share the use of lounge, kitchen, dining room and bathrooms. There is an enclosed garden that service users have access to. An extension is currently being built to provide an additional two bedrooms and separate lounge area. The home is situated in a rural location, approximately a mile from the centre of Botley and next to a pub. The manager reported that the highest fee at the home is £1735.80 per week, but did not have the figures for the lowest fee. Fees are determined by the assessed needs of service users. Mimosa Lodge DS0000052790.V315590.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The evidence used to write this report was gained from a review of the information the provider sent to the Commission for Social Care Inspection (CSCI) and a site visit to the home on 14th November 2006. During the site visit the inspector spoke with care staff on duty, the manager, and the area manager for Iliace. Two service users were spoken with directly and the interactions between other service users and staff were observed throughout the visit. A tour of the building was made and documents relating to the running of the home were inspected during the visit. What the service does well: What has improved since the last inspection? The providers are in the process of building an extension, which will provide an additional two bedrooms and separate lounge area. Mimosa Lodge DS0000052790.V315590.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Mimosa Lodge DS0000052790.V315590.R01.S.doc Version 5.2 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 Mimosa Lodge DS0000052790.V315590.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are good systems to assess the needs of service users before they move into the home. EVIDENCE: The files of four service users were inspected during the visit, one of who had moved into the home since the last inspection. Each contained an assessment of their needs that was completed before they moved into the home. This assessment covers the individual needs of service users, including communication, personal care and cultural needs. A copy of the service users’ care management assessment was also available. Documents reviewing the transition process were available for the service user who moved in most recently. Mimosa Lodge DS0000052790.V315590.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has good care planning systems, which are regularly updated and reflect the support that service users need. The risk assessment system is generally good, although assessments are not always updated following incidents, which does not ensure risks are minimised. Good support is provided to help service users make decisions about their lives. EVIDENCE: The personal files of four service users were inspected during the visit. Each service user had a care plan that was developed from their initial needs assessment and was regularly reviewed, either monthly or when the needs of service users changed. Care plans contain details of how service users should be supported to make decisions. Staff support service users to make decisions about activities they take part in by using Makaton sign language and objects of reference that have been developed for each service user. Throughout the visit, staff were Mimosa Lodge DS0000052790.V315590.R01.S.doc Version 5.2 Page 10 observed using these methods to support service users in their decision making. Risk assessments were in place for all four service users whose files were inspected. These documents set out the assessed hazards to service users and action to minimise the risk of harm. The risk assessments had also been regularly reviewed, either every two months or when the needs of service users changed. Amendments had been made to the risk assessments of two service users following a recent adult protection strategy meeting. Staff spoken with had a good understanding of the contents of the care plans and thought that the actions set out in the risk assessments helped to keep service users safe. The risk assessments for one service user did not contain any details of support staff should provide when they were physically aggressive, however, there was an incident recorded where they were aggressive towards another service user. The manager said this omission was an oversight and drew up a risk assessment and guidelines during the visit. Mimosa Lodge DS0000052790.V315590.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides good support for service users to take part in suitable activities, to maintain relationships with family and friends and provides good food. EVIDENCE: Service users are supported to take part in a range of educational and leisure activities. One service user spoken with said they like the activities they take part in and particularly like cooking. On the day of the visit, service users went out to a local outdoor activity centre. Service users’ files contained details of activities they had taken part in, including archery, trampolining, cooking, basketball and horticulture. Service users are supported to keep in touch with family and friends through visits, phone calls and letters. Details of the support service users need to complete household jobs, such as cleaning and cooking, are detailed in their care plans. The home has a planned menu that takes into account the likes and dislikes of service users and provides a varied and balanced diet. The meal service users Mimosa Lodge DS0000052790.V315590.R01.S.doc Version 5.2 Page 12 had during the visit included different options and service users appeared to be enjoying their food. Service users are encouraged to take part in preparation of their meals. Mealtimes are flexible to fit in with service users’ activities and the kitchen was well stocked with a variety of good quality food. Mimosa Lodge DS0000052790.V315590.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides good support to meet the personal care and health needs of service users. The medication systems in the home are good and protect service users. EVIDENCE: Details of the personal care support service users need are set out in their care plans. Staff spoken with demonstrated a good understanding of the needs of service users and how they should be met. Service users spoken with said that staff treat them well. Records are maintained of service users’ visits to health services, including GP, dentist, optician, community nurse and speech and language therapist. The records kept included details of any advice given by the practitioner. Medication was stored in a locked cabinet in the office and medication administration records had been fully completed, including a record of medication entering and leaving the home. All staff administering medication have undertaken training. None of the service users is currently administering their own medication. Mimosa Lodge DS0000052790.V315590.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are confident their complaints will be taken seriously and acted upon and the home has good adult protection systems, which help to keep service users safe, although this would be improved by training for all staff. Good procedures are in place to hold cash for service users, although systems for operating bank accounts do not protect service users’ money. EVIDENCE: The home has a complaints procedure available, which sets out who will deal with a complaint and how long the provider will take to respond to a complaint. The procedure has been supplied to all service users in a pictorial format to aid understanding. Service users spoken with said they would speak to staff if they wanted to make a complaint and were confident they would be taken seriously. The home has an adult protection policy and a copy of the local authority adult protection procedures. Most staff have received adult protection training and one staff member spoken with demonstrated a good understanding of abuse and action to take if abuse was reported or suspected. One staff member spoken with said she had not done any adult protection training and said she did not know the reporting process if she thought a service user was being abused. The money of two service users that was held by the home was inspected during the visit. The balance for both service users matched the records and receipts were available for purchases made on their behalf. The manager reported that money for one service user was being paid into an Iliace bank account as they were experiencing difficulties finding a bank that would open an account in the service user’s name. The manager reported that the records Mimosa Lodge DS0000052790.V315590.R01.S.doc Version 5.2 Page 15 of this account were not available in the home as they were held at Iliace head office. The manager reported that money was made available from head office when the service user needed it. Mimosa Lodge DS0000052790.V315590.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is well maintained and provides a safe, homely environment for service users, although using the home as an office for the organisation’s education staff may compromise privacy. EVIDENCE: A tour of the communal areas of the home was made during the visit. The home is well maintained and decorated throughout. Furnishings are domestic and of good quality. The home has an enclosed rear garden, which service users are able to access. The manager reported that the provider has a maintenance team and she has no problem getting work done when it is required. The home is currently being extended to provide an additional two bedrooms. Whilst this work is being completed, part of the lounge has been divided to ensure service users do not have access to the work site. Staff spoken with said this has had some effect on some service users, although support has been provided to help them cope with it. Risk assessments have been implemented to minimise the identified hazards during the work. Service Mimosa Lodge DS0000052790.V315590.R01.S.doc Version 5.2 Page 17 users spoken with said the building work had been noisy at times, but had not disturbed them very much. The home has a separate laundry room, which is not accessed through food preparation or storage areas. There are hand-washing facilities in the kitchen, laundry room, bathrooms and toilets. The “adults continuing education” (ACE) staff for Iliace are currently operating from an office in the home and have to go through the communal areas as there is not a separate entrance. The office they work from also contains the medication cabinet. The manager said she would look at finding alternative space for these staff that does not compromise the privacy of service users. Mimosa Lodge DS0000052790.V315590.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 34 and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has good systems to protect service users through robust recruitment checks. Most staff have received good training, although lack of training for some staff may mean staff lack understanding about service users’ needs. EVIDENCE: None of the fifteen staff employed have achieved the National Vocational Qualification (NVQ) at level two or above. The manager reported that four of the staff are currently completing the NVQ level three and would be supported to complete the work required. During the visit, staff were observed interacting with service users in a friendly and respectful manner. The records of four staff were inspected during the visit. These records contained two written references and a Criminal Records Bureau (CRB) disclosure. The manager reported that CRB disclosures had been obtained for all staff working in the home. The manager reported that the home currently has four full time staff posts vacant. Following a recent recruitment, the area manager reported that he had identified three staff and was hoping they would be ready to start by the end of the year. One staff member spoken with said that they received very good training, which helped them to meet the needs of service users. One staff member said Mimosa Lodge DS0000052790.V315590.R01.S.doc Version 5.2 Page 19 they had found attending training difficult because they worked part time, although they had caught up with most courses recently. The manager reported that changes in the way Iliace organises training for staff had caused some difficulties, as courses were not always available when needed and did not always have sufficient places for her staff. A record is kept of all training that staff have undertaken and staff appraisals include a training needs assessment. The training record indicated that a member of staff who works a night has not completed any training part from manual handling and health and safety. The manager reported that this member of staff had been booked onto training courses but had not attended and this issues was being dealt with in supervision. Staff complete an induction based on the learning disability awards framework. Courses staff have completed include first aid, medication administration, food hygiene, fire safety, health and safety, infection control, adult protection, moving and handling, epilepsy and Makaton sign language. Mimosa Lodge DS0000052790.V315590.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home’s quality assurance systems do not ensure that the manager is aware of actions the provider requires to improve the service. Action is taken to promote and protect the health, safety and welfare of service users and staff, although poor advice is given to staff about reporting incidents to CSCI. EVIDENCE: The manager is currently completing the Registered Manager’s Award and said she receives good support from the senior management staff and is able to speak with them whenever she needs to. Staff spoken with said that they felt well supported by the manager. The manager is not currently registered with CSCI, although has previously been registered for another Iliace service. In Mimosa Lodge DS0000052790.V315590.R01.S.doc Version 5.2 Page 21 discussions following the inspection, the manager confirmed that she would submit an application for registration to CSCI. The manager reported that formal service users’ meetings are not held, due to their communication needs. Individual meetings are held between service users and their keyworker. Records of these meetings are kept and used to assess any changes in the service that are required. The manager reported that senior managers from the providers visit the home each month to review the service quality, although the reports of these visits were not all available in the home. The latest report available in the home was for May 2006 and the manager said she would ensure she obtains these reports so she can take any action that is identified as necessary. The manager reported that they do not currently complete a survey of service users and their representatives, although a new quality assurance system was being introduced by Iliace, which will include a survey. The home has a fire risk assessment and regular checks are made of the fire warning system and the equipment. The gas system is serviced annually and annual tests of portable electrical appliances are completed. Assessments are completed for chemicals used in the home, which are stored in a locked cupboard. The temperatures of the fridge and freezer are taken daily and recorded. Accidents and incidents to service users and staff are recorded, however, these are not always reported to the appropriate authority. One incident was recorded in August 2006 where a service user pushed another service user to the floor, resulting in one service user sustaining cuts to their knees and hands and one service user being physically restrained by staff. This incident had been reported to adult services but the incident report stated that the staff member had been advised by the Iliace on-call manager that it was not necessary to inform CSCI. The area manager said he would find out why this advice was given and ensure that all managers who are on-call are aware of the correct procedures for reporting incidents. Mimosa Lodge DS0000052790.V315590.R01.S.doc Version 5.2 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. 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 3 3 X 4 X 5 X 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 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 3 3 X 3 X 2 X X 2 X Mimosa Lodge DS0000052790.V315590.R01.S.doc Version 5.2 Page 23 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. Standard YA23 Regulation 20 Requirement The registered person must ensure that service users’ money is not deposited into accounts that are not in the service users’ name. The registered person must ensure that all staff receive training suitable to the needs of service users. The registered provider must ensure that reports of their monthly visits to the home are provided to the manager. The registered person must ensure that all events which adversely affect the well-being or safety of service users are reported to the Commission for Social Care Inspection. Timescale for action 31/12/06 2. YA35 18(1) 31/01/07 3. YA39 26(5) 31/12/06 4. YA42 37 31/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Mimosa Lodge DS0000052790.V315590.R01.S.doc Version 5.2 Page 24 Mimosa Lodge DS0000052790.V315590.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Mimosa Lodge DS0000052790.V315590.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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