Inspection on 06/06/05 for Mimosa Lodge

This inspection was carried out on 6th June 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Mimosa Lodge 27/07/07

Mimosa Lodge 14/11/06

Mimosa Lodge 13/10/05

Mimosa Lodge 23/09/04

Mimosa Lodge 13/04/04

Mimosa Lodge 08/01/04

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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 SO32 2DH Lead Inspector Pat Hibberd Unannounced 6.06.05 10:00 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. Mimosa Lodge H54 S52790 Mimosa Lodge V218812 6.06.05.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Mimosa Lodge Address Winchester Road Botley Southampton Hampshire SO32 2DH 01489 789612 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) Iliace Limited Mr Benjamin Jon Tindall CRH 7 Category(ies) of LD Learning Disabilities registration, with number of places Mimosa Lodge H54 S52790 Mimosa Lodge V218812 6.06.05.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 23.09.04 Brief Description of the Service: Mimosa Lodge is one of a number of Homes owned by Iliace Ltd a private company. Mr Ben Tindell is the Homes manager. The Home opened in September 2003 and provides care and accommodation for seven Service Users with a learning disability. The Home is a large detached property with seven bedrooms. There is ample communal space and a number of bathrooms some of which have shower facilities. To the front and rear of the property are large gardens which are secured by fencing and a gate. There is a separate office in the grounds. Mimosa Lodge is situated on the outskirts of the village of Botley and within 20 minutes drive of the city of Southampton which has a range of leisure, shopping and recreational facilities. The Home have their own transport which is unmarked and provides transport for service Users to access both the local and wider community. Mimosa Lodge H54 S52790 Mimosa Lodge V218812 6.06.05.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over four hours and was the first unannounced inspection of the 2005/2006 inspection programme. Fifteen of the forty three Standards relating to Younger Adults were assessed on this occasion. Four areas of improvement were identified and required to be addressed by the manager. Details can be found at the end of this report. Four of the five requirements identified at the last inspection have met . The inspection included a tour of the Home; including five Service User’s bedrooms and the garden. Discussions were held with two staff members on duty and the Home’s manager. Due to the limited verbal communication of some of the Service Users accommodated the inspector also observed practices in the Home with a view to gaining an understanding of how needs were being met. Three Service User’s files were viewed and care provided by the Home assessed and discussed with the manager and staff. What the service does well: From observations of practices and discussions held with staff and the manager it was evident that the team remain very committed to their individual roles with Service Users central to care provided. Where able Service Users are encouraged to take an active role in the day to day running of the Home. Training is ongoing with staff feeling well supported by the manager. There are a variety of activities provided and offered to Service Users with a view to promoting confidence and a degree of independence as appropriate. Mimosa Lodge H54 S52790 Mimosa Lodge V218812 6.06.05.doc Version 1.30 Page 6 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. Mimosa Lodge H54 S52790 Mimosa Lodge V218812 6.06.05.doc Version 1.30 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 Mimosa Lodge H54 S52790 Mimosa Lodge V218812 6.06.05.doc Version 1.30 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 and 2 The pre assessment process of Service Users care requirements needs to improve. Service User guides are not in a format suitable to individual needs. EVIDENCE: The Home has an extremely comprehensive process of assessment which includes four areas of need. The first is a personal profile of the individual, the second skills maintenance , the third work placements and finally behavioural guidelines . One file was viewed relating to a recent admission to the Home. The information was generally very informative with evidence that the Service User had had a number of visits prior to moving in and a range of assessments having been undertaken. However, there were no risk assessments available or care plan completed to inform care staff of the individuals support needs. Mimosa Lodge H54 S52790 Mimosa Lodge V218812 6.06.05.doc Version 1.30 Page 9 There was a care management assessment available and evidence that the individual , family and professionals had been consulted as to the appropriateness of the placement. The inspector met with one Service User who had moved to the Home during the previous weekend. They were in their bedroom where they were unpacking their personal effects. They were able to indicate that it was their new bedroom and appeared happy and relaxed with their new surroundings. A further requirement identified related to Service User guides. They have not been produced in a format that is accessible for those for whom the service is intended. There is a Statement of Purpose available in a written format. However, the manager confirmed that there are no Service User’s currently accommodated who can read . Mimosa Lodge H54 S52790 Mimosa Lodge V218812 6.06.05.doc Version 1.30 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 and 9 The arrangements for care planning are consistent for most Service Users ensuring their care needs are met and they are not placed at risk. EVIDENCE: Two Service User’s files were viewed and care “tracked” with staff and one Service User through discussion and observation. Care plans had been completed for both individuals. In general the information was informative with details of the support required to ensure their needs are being met. Service Users views as to care provided have been captured through a continuous process of monitoring /observation by the staff team. There were Care Management assessments available in the Service User’s files with evidence that the local Community Health Teams were involved with individuals as necessary. Reviews had taken place for both Service User’s. Mimosa Lodge H54 S52790 Mimosa Lodge V218812 6.06.05.doc Version 1.30 Page 11 A requirement was identified however, in relation to the lack of risk assessments and behavioural guidelines for one Service User who had been accommodated since December 2004 . Time was spent with one of the Service Users to enable the inspector to observe practices in the Home. Particular emphasis was placed on staff communication with the individual in relation to how they were to spend their day and how it reflected identified needs in their care plan. Discussions held with staff confirmed that they were aware of Service User’s needs and care plans were being implemented. Daily records are completed for all Service Users with shift “handovers” taking place with a view to ensuring continuity of care. Mimosa Lodge H54 S52790 Mimosa Lodge V218812 6.06.05.doc Version 1.30 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,15 and 17 Links with the local community are good with Service Users having opportunities for appropriate activities based on their interests. Menus are well balanced, creative and offering choice ensuring the dietary needs of Service Users are met. EVIDENCE: The Organisation has an ‘activities ‘ team and together with the home staff they endeavour to ensure Service Users have a community presence by devising programmes of activities for Service Users. These include music and movement, craft, visits to the pub, walks, attendance at college , gardening and singing. Observations were made of Service User’s choosing what they wished to do through speech and sign language. Mimosa Lodge H54 S52790 Mimosa Lodge V218812 6.06.05.doc Version 1.30 Page 13 The Home has a daily activities/ communication board in the communal area which is in a pictorial format endeavouring to support Service Users to gain an understanding of their day ahead. Objects of reference are also used to inform Service User’s of activities they may wish to participate in. There are no Service User’s accommodated who undertake any form of paid/unpaid employment. Two files viewed confirmed that Service Users interests are pursued and individual programmes devised . Two staff spoken to confirmed there are sufficient staff on duty during the evening and weekends to support activities identified. The Home has two unmarked vehicles with the majority of staff insured to drive Service Users to their activities or community events. There are currently no Service Users accommodated who would understand the concept of voting. The manager confirmed that this would be pursued if appropriate for an individual. Menus were seen to be well balanced with a dietician having been consulted as to their nutritional value. Menus are in a written format . However, with none of the Service Users accommodated being able to read they are not accessible to individuals. The manager indicated that this is a piece of work being undertaken by the Organisation and will be followed up at the next inspection. Where able Service Users are actively involved in the planning/shopping and preparation of meals. Service User were not observed eating although staff confirmed that snacks were always available and an alternative would always be offered to individuals. Mimosa Lodge H54 S52790 Mimosa Lodge V218812 6.06.05.doc Version 1.30 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19 and 20 Personal care routines and health needs of Service Users are met with evidence of good multidisciplinary working taking place on a regular basis. Records and guidelines relating to the administration of medication to Service User’s requires some improvement. EVIDENCE: Daily routines pertaining to personal care provided to individuals were recorded in two care plans viewed with clear instructions to staff as to how to support the individual. Staff were able to describe their understanding and application to service provision with observations supporting this view. Independence and privacy for individuals was clearly paramount from discussions held with staff. Service User’s have access to a GP and specialist health care services as required of which evidence was documented in two files viewed. The Home has a medication policy and procedure which is shared with all staff during their induction and, following any amendments made by the management team of the Organisation. Records viewed confirmed that medication administered by staff had been signed for with medication seen to be appropriately stored with Service Users having their own individual box in the medication cupboard. Mimosa Lodge H54 S52790 Mimosa Lodge V218812 6.06.05.doc Version 1.30 Page 15 There were, however, two areas that require improvement in relation to “as required “medication administration and the need to update the relevant policy. From two care plans viewed it was evident that guidelines/instructions to staff in relation to the administration of prescribed “ as required “ medication for two Service User’s had not been written. The manager indicated that all staff had received in house safe handling of medication training . A discussion was held with the Organisations Training Manager who confirmed that he will be arranging for care staff to attend a course at a local college as soon as this can be arranged. In the interim care staff will continue to use the Organisations internal safe handling of medication training packs/guidance. Staff have received rectal diazepam training from a health professional. However, on inspection of the Home’s medication policy and procedure relating to invasive procedures it was evident that it had not been updated to reflect the Organisation’s guidance to staff of which the Commission had been sent a copy last year. There are no Service User’s who self medicate. Mimosa Lodge H54 S52790 Mimosa Lodge V218812 6.06.05.doc Version 1.30 Page 16 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) No Standards were assessed on this occasion. EVIDENCE: Mimosa Lodge H54 S52790 Mimosa Lodge V218812 6.06.05.doc Version 1.30 Page 17 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 and 30 The Home is clean and well maintained , decorated and suitably furnished and provides a comfortable environment to meet the needs of Service Users. EVIDENCE: The Home was clean, bright and hygienic with policies and procedures and systems in place including infection control /Control of Substances Hazardous To Health ( COSHH )/food hygiene and moving and handling training for staff . Staff spoken to confirmed that they were aware of their responsibilities in relation to hygiene in the Home , were provided with gloves and aprons as required and had received infection control training. There is a separate laundry and ample hand washing facilities around the Home. A contract is in place for the collection of clinical waste. Furniture and fittings in the communal areas of the Home are of a good standard and domestic in appearance. Mimosa Lodge H54 S52790 Mimosa Lodge V218812 6.06.05.doc Version 1.30 Page 18 Five Service Users bedrooms were seen to be individually decorated , well furnished, had adequate storage facilities and personal effects. The manager advised that Service Users where able would be involved in the decorating of both the communal areas of the Home and their individual bedrooms. All bedroom doors are lockable but there are currently no Service Users who hold their own key because of their particular needs. This needs to be documented in Service User’s care plans. Routine maintenance is undertaken by the Organisation’s maintenance team. There has been no recent visits made by the Environmental Health department or Statutory Fire officer. Mimosa Lodge H54 S52790 Mimosa Lodge V218812 6.06.05.doc Version 1.30 Page 19 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) 34,35 and 36 The Home has a well trained and supervised staff team ensuring Service Users’ needs are appropriately met. The Home’s recruitment practices do not protect Service Users . EVIDENCE: The Organisation have a recruitment policy and procedure with all staff being interviewed by the home’s manager and a personnel officer. However, during discussion with the manager it was evident that two staff had been employed and were working in the home without a Criminal Record Bureau (CRB)check having been received . The manager advised the inspector that he had also attempted to apply for a POVA FIRST check but that the application had been unsuccessful to date. Both members of staff were informed by the manager on the day of the inspection that until satisfactory checks had been received they could not work in the home. The manager was advised that he should update and familiarise himself with the CRB guidelines and ensure no staff were employed unless the guidelines were followed. Two references are always undertaken prior to employment . All staff undertake an induction period of training and undergo a three month probationary period before confirmation of employment. Mimosa Lodge H54 S52790 Mimosa Lodge V218812 6.06.05.doc Version 1.30 Page 20 The Organisation has a training programme with the home’s manager and Training Officer for the Organisation having responsibility for training of staff. A range of training has been undertaken by staff with requirements from the last inspection relating to the need for staff to receive fire, food hygiene and infection control training having been met. Staff spoken to advised the inspector that they considered the training to be good and meeting their needs and the needs of Service Users. Some staff are undertaking National Vocational Training (NVQ’s) . The manager indicated that there remains a number of staff however, who have not commenced the training and discussions are being held with the Training Officer as to when the courses can begin for staff. Staff further confirmed that they are now receiving supervision and had had an appraisal. This meets a requirement identified at the last inspection. Mimosa Lodge H54 S52790 Mimosa Lodge V218812 6.06.05.doc Version 1.30 Page 21 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) No Standards were assessed on this occasion. EVIDENCE: Mimosa Lodge H54 S52790 Mimosa Lodge V218812 6.06.05.doc Version 1.30 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 2 x x x Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 x x 3 x 3 Standard No 31 32 33 34 35 36 Score x x x 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Mimosa Lodge Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score x x x x x x x H54 S52790 Mimosa Lodge V218812 6.06.05.doc Version 1.30 Page 23 yes 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 1 Regulation 5 Requirement Timescale for action 6/8/2005 2. 6 15 3. 20 13 The Registered Provider must ensure Service User Guides are produced for individuals in a format they can understand. (previous timescale of 24/11/2005 not met). The Registered Providers must 6/7/2005 ensure Service User care plans/risk assessments are up to date, reviwed and shared with all staff. The Registered Provider must 11/6/2005 ensure care plans detail instructions to staff as to the administration of prescribed as required medication. The Registered Provider must ensure care staff do not commence work until they have undertaken a POVA First check and a Criminal Record Bureau Check. 11/6/2005 4. 5. 34 19 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Mimosa Lodge H54 S52790 Mimosa Lodge V218812 6.06.05.doc Version 1.30 Page 24 No. 1. Refer to Standard Good Practice Recommendations Mimosa Lodge H54 S52790 Mimosa Lodge V218812 6.06.05.doc Version 1.30 Page 25 Commission for Social Care Inspection 4th Floor Overline house Blechynden terrace Southampton SO15 5BT 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. 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