Inspection on 27/07/07 for Mimosa Lodge

This inspection was carried out on 27th July 2007.

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

Mimosa Lodge 14/11/06

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

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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 Hampshire SO32 2DH Lead Inspector Nick Morrison Unannounced Inspection 27th July 2007 10:00 Mimosa Lodge DS0000052790.V341179.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.V341179.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.V341179.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mimosa Lodge Address Winchester Road Botley Southampton Hampshire 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 Suzanne Curle Care Home 9 Category(ies) of Learning disability (0) registration, with number of places Mimosa Lodge DS0000052790.V341179.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Learning Disabilities (LD) The maximum number of service users to be accommodated is 9. Date of last inspection 14th November 2006 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.V341179.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report represents a review of all the evidence and information gathered about the service since the previous inspection. This included a site visit that occurred on 27th July 2007 and lasted six hours. During this time the Inspector toured the premises, looked at the files of four service users and observed the service people were getting. The Inspector also met with the Manager and five members of staff and observed interaction between staff and service users. All records and relevant documentation referred to in the report was seen on the day of the inspection visit. The Inspector also referred to service’s own self-assessment of the home and spoke with three parents and four service users. What the service does well: What has improved since the last inspection? 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.V341179.R01.S.doc Version 5.2 Page 6 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.V341179.R01.S.doc Version 5.2 Page 7 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): 2 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users benefit from having their needs and aspirations assessed prior to moving into the home. EVIDENCE: The home undertakes its own assessment of people prior to them moving into the home. Assessments were comprehensive and included a life history of the person. Parents spoken with said they were involved in this process and that they felt this was done very positively and were reassured by having the opportunity to ensure that the home was fully aware of the person before they moved in. Records showed that all assessments were in place prior to the person moving in and that the Manager of the home had met with people at their previous residence to carry out the home’s assessment wherever possible. Mimosa Lodge DS0000052790.V341179.R01.S.doc Version 5.2 Page 8 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): 6, 7 and 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users benefit from having clear care plans and risk assessments in place and from being supported to make their own decisions. EVIDENCE: Individual care plans were in place for each person living in the home and were clearly related to the initial assessment and the ongoing information the home had gathered on each person over time. The plans were well written and explained not only what staff needed to do in order to support people well, but also the reasons why. Staff spoken with were clear about individual care plans and had all signed to say they had read and understood them. Service users and parents spoken with said they were involved in the care planning process and that the home kept them informed of changes to the plans as they occurred. The care plans were individualised and contained photographs of the service user and their keyworker. Each person Mimosa Lodge DS0000052790.V341179.R01.S.doc Version 5.2 Page 9 had a review once or twice a year and parents and service users and parents were involved in these and were able to contribute to the care planning process. In addition, the home had just introduced monthly keyworker meetings where the service user met with their keyworker on a monthly basis to review their month in relation to their care plan, to monitor medical and other appointments and to plan for the coming month. There was a daily diary for each service user and this was used to record what they had done during the day and how this related to their care plan. The home is planning to introduce a system of person centered planning to ensure that care plans are, as far as possible, based on the aspirations of people who use the service. Care plans contained information on how each person preferred to be supported and how they communicated decisions and staff spoken with were clear that service users had the right to make their own decisions about their own lives. This was confirmed in discussion with service users and their families. Risk assessments were clearly written and reviewed on a regular basis. Staff spoken with were clear about risk assessments for each person and the importance of supporting people in line with the risk assessments. Risk assessments were used to promote independence and support people living in the home to be involved safely in the activities they wanted to do. Mimosa Lodge DS0000052790.V341179.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 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. Service users benefit from having their rights respected and from balanced and nutritious meals. They also benefit from having the opportunity to engage in a wide range of activities both inside and outside of the home. EVIDENCE: People living in the home each have a timetable of activities which, from observation throughout the inspection visit, were followed. Staff support was managed so that each person had the necessary support to do the activities they wanted to do. From observation and from discussion with people living in the home it was also clear that people were able to choose whether or not to take part in the activities offered to them. Activities for people living in the home were organised by the company’s activity staff who were based at the home but also provided activities for people in other homes owned by thje same organisation. Activities included using the local college, the local Mimosa Lodge DS0000052790.V341179.R01.S.doc Version 5.2 Page 11 activities centre, trampolining, rambling, swimming, horticulture, cookery, numeracy, literacy and arts and crafts. The service was also planning to give some people the option to try voluntary work in the future. Service users spoken with said they enjoyed the activities in the home and some had chosen the home partly because of the amount and range of activities on offer. Parents spoken with were happy with the amount of activities in the home and said it had been beneficial to their sons and daughters by being introduced to new activities, by being more physically active and healthy and by helping people improve their social skills. There was a lot of support for people living in the home to maintain contact with their families. The visiting policy promoted and encouraged visitors. People living in the home were supported to telephone their families whenever they wanted to and were able to do this private. One person living in the home is supported to fly to Yorkshire to visit her mother. Parents also said they felt able to visit and telephone the home at any time and that staff were always helpful, respectful and reassuring. Food in the home was of good quality and people observed during the inspection visit appeared to enjoy their meal. The menu’s showed that the diet was varied and nutritious. Individual preferences were recorded so that people did not have food they didn’t like. There was sufficient staff support throughout the mealtime and staff tried to ensure that mealtimes were an enjoyable time for people living in the home. Parents spoken with said staff in the home had supported their daughter to manage her weight by helping and supporting her to choose healthy options Mimosa Lodge DS0000052790.V341179.R01.S.doc Version 5.2 Page 12 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): 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. Service users benefit from having their healthcare needs met and are protected by the home’s medication policies and practices. EVIDENCE: Care plans contained information on how people preferred to be supported with their personal care. The files of people living in the home demonstrated that healthcare needs were monitored and that people were supported to use healthcare services as necessary. Each person living in the home had a Health Action Plan on their file which assessed their health needs and identified relevant actions. Service users spoken with were aware of these and were aware of their own health needs. Where people had used healthcare services there were records detailing the time and date, the reason why they attended and any outcomes as a result of the consultation. Staff in the home liaised closely with healthcare professionals in the interests of people living in the home. Mimosa Lodge DS0000052790.V341179.R01.S.doc Version 5.2 Page 13 The system for administering medication in the home was clear and was stated in the home’s policies. Staff spoken with who were involved in administering medication said they had received good training and demonstrated that they had a good understanding of medication issues. Medication records were clear and up-to-date and all medication was stored appropriately and safely. Where people living in the home had been prescribed various ‘as required’ medications to control very difficult behaviour in unsafe situations, there were clear plans in place on how these may be administered and the plans placed a strong emphasis on using alternative intervention techniques before resorting to medication. Records showed that such medications were used very little in the home. Mimosa Lodge DS0000052790.V341179.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): 22 and 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users benefit from having their views listened to and are protected by the homes policies and practices. EVIDENCE: There had been a requirement from the previous inspection that the registered person must ensure that service users’ money is not deposited into accounts that are not in the service users’ name. This has now been addressed and the requirement is met. The service did a good job of protecting people living in the home. There were clear policies in place covering complaints, whistleblowing and protecting vulnerable adults. Staff spoken with were clear about these policies and they had been covered in-depth during their induction training and throughout further training on specific topics. The complaints policy had been put into a format designed to be more accessible to people living in the home and parents and service users spoken with confirmed they had received a copy of the policy and were clear about how to make a complaint if they felt the need to. There was a clear system in place for recording and responding to complaints, but no complaints had been received over the past twelve months. There was a record on each person’s file of the personal property they had in the home. Service users spoken with said they felt safe in the home. Mimosa Lodge DS0000052790.V341179.R01.S.doc Version 5.2 Page 15 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): 24 and 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users benefit from living in a clean, comfortable and safe environment. EVIDENCE: The home had been adapted and designed to provide a stimulating, safe and comfortable environment for people. The home employs a maintenance person to deal with the upkeep of the building and the maintenance book showed that issues were dealt with quickly.. The service aims to maintain a homely feeling in the house and the furniture and fittings are domestic and comfortable. Service users were encouraged to be involved in choosing colours and furniture for the communal parts of the home as well as for their own individual rooms. The service employs a housekeeper and the home was kept clean throughout. Clear infection control policies were in place and staff spoken with were aware Mimosa Lodge DS0000052790.V341179.R01.S.doc Version 5.2 Page 16 of these and of the need to maintain a comfortable and appealing environment for people living in the home. Service users and parents spoken with said the home was always clean, but still comfortable and “lived in”. Mimosa Lodge DS0000052790.V341179.R01.S.doc Version 5.2 Page 17 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): 32, 34 and 35 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users benefit from being supported by adequate numbers of welltrained staff and are protected by the home’s recruitment policies and practices. EVIDENCE: There had been a requirement from the previous inspection that the registered person must ensure that all staff receive training suitable to the needs of service users. This requirement has now been met. Staff training records showed that people working in the home received a wide range of training opportunities relevant to their work. Currently there are only forty-eight per cent of staff working towards an NVQ2 or equivalent within the home. The Manager had identified this as an urgent and had a meeting planned with the training manager in the week following the site visit. The Manager’s aim is to increase this percentage as soon as possible and she feels the organisation is committed to achieving this. Staff spoken with were knowledgeable and demonstrated skills and understanding in working with people who have a learning disability. They also reported that the training they Mimosa Lodge DS0000052790.V341179.R01.S.doc Version 5.2 Page 18 received was informative and interesting. Training needs were formally identified with the line manager and they were also supported to attend other courses that came up which they had a particular interest in. The home has a three monthly training plan in place. The organisation has appointed a training manager to ensure that all staff are receiving all the training they need. Rota’s showed that there were sufficient staff on duty at all times. Staffing consisted of four staff during the day, three during the evenings and one night styaff supported by a member of staff sleeping-in. In addition to the care staff there was the housekeeper, Manager and administrative staff. Staff spoken with and observed during the inspection visit were conscientious, enthusiastic, skilled and focussed on the needs of people living in the home. Recruitment records demonstrated that staff are not employed in the home without all necessary checks being in place, including references, Criminal Records Bureau check and POVA First check. Mimosa Lodge DS0000052790.V341179.R01.S.doc Version 5.2 Page 19 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): 37, 39 and 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users benefit from living in a well-managed home that is safe and responsive to their needs. EVIDENCE: There had been a requirement from the previous inspection that 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. This has now been met. There is evidence that such incidents have been reported and there was no evidence of incidents that should have been reported but were not. Mimosa Lodge DS0000052790.V341179.R01.S.doc Version 5.2 Page 20 There had been a requirement from the previous inspection that the registered provider must ensure that reports of their monthly visits to the home are provided to the manager. This has now been met as there were records of these visits kept at the home. The Manager of the home is registered and has demonstrated that she has the skills, knowledge and training to manage the service. Staff, service users and parents spoken with during the inspection process spoke highly of the Manager saying that the service had improved in a number of ways since she took up her post. Some parents said that the Manager was good at demonstrating the kind of approach staff should have to their work and to the people living in the home and that this demonstrated good leadership. In discussion the Manager was able to demonstrate that she has a clear understanding of the issues within the home and is able to manage them effectively. She also has developmental plans in place for the home. The organisation has comprehensive quality assurance processes that are about to be put in place. These include internal audits, questionnaires for people who live in the home and their representatives, staff involvement, Directors’ reports and audits of the service by other home managers in the organisation. Health and safety is well managed in the home. All equipment is serviced and checked regularly, maintenance issues are dealt with, incidents and accidents are recorded and regularly audited and good workplace risk assessments were in place. Fire records were up-to-date. There were no outstanding health and safety issues in the home at the time of the inspection. Mimosa Lodge DS0000052790.V341179.R01.S.doc Version 5.2 Page 21 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 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 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 3 X X 3 X Mimosa Lodge DS0000052790.V341179.R01.S.doc Version 5.2 Page 22 No 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. 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. Refer to Standard Good Practice Recommendations Mimosa Lodge DS0000052790.V341179.R01.S.doc Version 5.2 Page 23 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.V341179.R01.S.doc Version 5.2 Page 24 - 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!