Inspection on 16/03/07 for Mount Lodge

This inspection was carried out on 16th March 2007.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mount Lodge 19/02/08

Mount Lodge 06/09/05

Mount Lodge 22/04/05

Mount Lodge 26/08/04

Mount Lodge 17/05/04

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

CARE HOME ADULTS 18-65 Mount Lodge 5 Upper Avenue Eastbourne East Sussex BN21 3UY Lead Inspector Kathy Flynn Key Unannounced Inspection 16th March 2007 12:00 Mount Lodge DS0000021169.V307346.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 Mount Lodge DS0000021169.V307346.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. Mount Lodge DS0000021169.V307346.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mount Lodge Address 5 Upper Avenue Eastbourne East Sussex BN21 3UY 01323 411312 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) Community Housing and Therapy Ms Rosanna Basso Care Home 16 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (16) of places Mount Lodge DS0000021169.V307346.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is sixteen (16). That service users are aged between eighteen (18) and sixty-five (65) years on admission. That only service users with a mental disorder, excluding learning disability or dementia, to be admitted. 6th September 2005 Date of last inspection Brief Description of the Service: Mount Lodge, first registered in 1993, is a therapeutic community run by Community Housing and Therapy, (CHT), for 16 adults, between the ages of 18 and 65, who are experiencing mental health and emotional difficulties, excluding learning disability or dementia. Many service users (clients) have ‘dual diagnosis’ and in addition to their psychiatric condition may also have problems with substance misuse. The premises comprise of a large, three storey detached house, with an extensive garden to the rear and parking space at the front of the building. Service user accommodation comprises of single rooms, each fitted with a wash basin Communal areas include two large lounges, a separate dining room, an additional quiet lounge and a kitchen and laundry room. Sufficient toilets and bathrooms are provided throughout. The home is situated in a residential area of Eastbourne, a short walk from the town centre amenities, including shops and the main line railway station. A local bus service passes near by. Service user involvement is a significant aspect of the organisation’s approach to community care. Regular group discussion meetings form the basis for much of the structured work within the community. Independence and self awareness is promoted within the community and service users are encouraged to contribute to the day to day running of the home, including cleaning and planning and preparing meals. Mount Lodge DS0000021169.V307346.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 16th and 21st March over 6 hours. A pre-inspection questionnaire and ten service users surveys were sent to the home prior to the inspection. The questionnaire and five surveys were completed and returned to the Commission. The inspection included a tour of the home with a member of staff. Documentation including care plans, staff training, staff files, Medication Administration Records and the homes policies and procedures were examined. While others, such as quality assurance questionnaires, were discussed with staff and the acting manager. Service users were taking advantage of the warm weather during the inspection. One was available to discuss the support provided at Mound Lodge, as were the staff on duty and the acting manager. What the service does well: What has improved since the last inspection? What they could do better: Care plans, including risk assessments, should be reviewed when service users needs change. Service users comments should also be included in the care plans so that they and the staff can see positive developments during their time at the home. Mount Lodge DS0000021169.V307346.R01.S.doc Version 5.2 Page 6 Medicine Administration Records were found to be incomplete, additional training or action should be taken to ensure the service users are protected. An effective quality assurance system should be developed, seeking feedback from service users and relatives, as well as advocates and health professionals where appropriate, to ensure the services provided are appropriate to the needs of service users. 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. Mount Lodge DS0000021169.V307346.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 Mount Lodge DS0000021169.V307346.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 at least once during a 12 month period. 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. A full needs assessment is completed, by individuals qualified to do so, prior to service users being admitted to Mount Lodge. EVIDENCE: Prospective service users are invited to visit the home, look around and meet existing service users and staff, they may also stay overnight if they wish. They are formally assessed using an interview format, with supporting information from the prospective service users local health authority, including a full psychiatric assessment and social history. During the inspection the importance of the compatibility of service users was discussed by staff and a six week trial period, with ongoing assessments, is used to ensure they have the potential to benefit from the community. All referrals and applications to the home are discussed with staff and existing service users and at the end of the trial period service users are actively involved in deciding if a long term placement is to be offered. Mount Lodge DS0000021169.V307346.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 at least once during a 12 month period. 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 care plans are developed from comprehensive assessments of their individual support needs to enable staff to meet these needs. Service users are supported to take risks as part of an independent lifestyle. EVIDENCE: An individual care plan, ‘Therapeutic Curriculum’ has been developed for each service user at Mount Lodge. Each plan contains the service users personal details, social and professional contacts, details of current issues and needs, as well as future aims and goals, in the form of short and long term aims, as part of an agreed plan of action. Mount Lodge DS0000021169.V307346.R01.S.doc Version 5.2 Page 10 It was noted that the care plans examined were not reviewed when the service users needs had changed, and there was no record of service users comments regarding the aims and goals that had been agreed with staff. Staff confirmed that service users can make decisions about their lives and choose how they spend their time as part of an independent lifestyle, within the agreed limits and risk assessments recorded in the care plan. On the first day of inspection most of the service users went out to enjoy the warm and sunny weather. Staff confirmed that the community meetings, from Monday to Friday, are generally well attended and other groups for cooking, cleaning and gardening have been arranged for service users to attend it they wish. Each service user has a one-to-one session with their key worker, and all are involved in meal preparation and shopping. Mount Lodge DS0000021169.V307346.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 at least once during a 12 month period. 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. Independence is promoted within the home with service users able to come and go as they choose. Staff support service users to become part of the local community and maintain family links and friendships. Service users and staff work together to provide a wholesome and balanced diet. EVIDENCE: The routines and rules at the home are flexible and promote independence and individual choices, subject to the restrictions agreed in the service users care plan. Mount Lodge DS0000021169.V307346.R01.S.doc Version 5.2 Page 12 The manager confirmed that there are opportunities to participate in the local community, in terms of work or education, and some service users do take part in these activities depending on their assessed needs. Family links are supported and service users are able to visit relatives or invite them to Mount Lodge if they wish. A catering group has been set up to review the meals provided and decide future menus. Staff confirmed that they work with the service users to prepare and cook the meals and join them at meal times. Mount Lodge DS0000021169.V307346.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 at least once during a 12 month period. 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. The health needs of service users are well met with access to other health professionals arranged as required. The systems for the administration of medicines are poor and may put service users at risk. EVIDENCE: Health care professionals from the community psychiatric services maintain regular links with the home, and the care needs of service users are reviewed with them on a regular basis. The service users are registered with GP’s and they have access to allied health professionals including dentist when they wish. There are two service users responsible for their medication, they are given their medication weekly and risk assessments have been completed. Mount Lodge DS0000021169.V307346.R01.S.doc Version 5.2 Page 14 Medicine administration records (MAR) were examined and some were found to be incomplete. There were a number of gaps where staff had failed to sign that a service users had received or not received the appropriate medication. The member of staff responsible for medicines at the home explained that the systems have been improved following a visit from the pharmacy inspector some time ago. Part of the improvement was for staff to sign that medicines had been given or fill in the MAR charts with the appropriate letter to show if they had refused or were not in the home at the time. The manager and staff have clearly identified that failure to complete the charts caused confusion and fails to ensure that service users have taken appropriate medicines. The manager confirmed that they will be looking at introducing a system that checks the MAR charts daily, and identifies individuals who are failing to follow the home policies and procedures. Mount Lodge DS0000021169.V307346.R01.S.doc Version 5.2 Page 15 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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The open and inclusive atmosphere enables service users and staff to express any concerns they have and feel they will be listened to. Policies and procedures are in place to protect service users from abuse. EVIDENCE: The staff confirmed that the home has a satisfactory complaints system in place. No complaints have been made about the services provided at Mount Lodge to the home or the Commission since the last inspection. Policies and procedures are in place regarding adult protection and staff confirmed that training is provided and they have attended. Mount Lodge DS0000021169.V307346.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 at least once during a 12 month period. 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. Standards of cleanliness in Mount Lodge have improved and communal areas are generally clean and comfortable to live in. EVIDENCE: The standard of decor in the home is variable, the rear lounge has recently been decorated, and the dining room and hallway are cleaned regularly and are quite comfortable. But the stairs and hallways on the first floor require thorough cleaning and the staff advised that this would be addressed as part of the spring-cleaning programme, which would be organised to involve all staff and service users. Individual service users rooms were not viewed, although an empty room, which has been decorated was noted to be comfortable and homely. Mount Lodge DS0000021169.V307346.R01.S.doc Version 5.2 Page 17 The manager advised that there are plans to re-decorate all the rooms as part of an improvement plan for the building, however the maintenance is carried out by members of staff who are employed by the group of home and it may be some time before the bathrooms, which have peeling ceilings are updated. Mount Lodge DS0000021169.V307346.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 at least once during a 12 month period. 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. The staff have a sound understanding of service users needs, and there are sufficient trained staff on duty at all times. Recruitment procedures are carried out by head office. To ensure the protection of service users staff are not employed in the home until all relevant checks are completed. EVIDENCE: Staff are required to complete induction and foundation training, as well as fire safety, safe handling of medicines and food hygiene. Moving and handling training was discussed with the manager with regard to service users moving large pieces of furniture when carrying out cleaning in the home. The manager confirmed that she has completed this training and will be able to train staff in this area. The personnel files at Mount Lodge included some information about staff, in particular supervision records. The manage advised that head office in London Mount Lodge DS0000021169.V307346.R01.S.doc Version 5.2 Page 19 is responsible for the recruitment of staff and will do all the necessary checks, each home is then advised when they have been completed and on what date any new members of staff may start work at the homes. The manager confirmed that copies of relevant documentation would be obtained for the staff files so that they can be viewed at the next inspection. Staff at the home are all psychology graduates and are working towards the Diploma in Dialogical Group Therapy for therapeutic community practitioners, a three year course accredited by Middlesex University. Mount Lodge DS0000021169.V307346.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 at least once during a 12 month period. 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 are protected by up to date policies and procedures for health and safety. The home quality monitoring system is not used effectively to obtain feedback from service users, family members, advocates or other stakeholders in the community. EVIDENCE: The acting manager has been employed at the home for one week and is currently completing the induction programme, she has worked at Mount Lodge before and has experience of providing support for individuals with Mount Lodge DS0000021169.V307346.R01.S.doc Version 5.2 Page 21 mental health problems. She will be applying to register as manager with the Commission. The homes quality assurance and monitoring system is in place but service user questionnaires have not been used to obtain feedback from service users, family, friends, advocates or allied health professionals. The acting manager confirmed that she will be addressing this in the near future. Mandatory training in fire safety, food hygiene and fist aid is provided for staff, and a member of staff has taken the lead for health and safety at the home after completing the appropriate training. Mount Lodge DS0000021169.V307346.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 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 2 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 2 X 3 X 2 2 2 3 2 Mount Lodge DS0000021169.V307346.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? YES 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 YA6 Regulation 15 (2)(b) Requirement It is required that service users care plans, including risk assessments are regularly reviewed and updated to reflect the changing needs of service users, to include their comments and agreements. This requirement is outstanding from April 2005. It is required that staff follow the homes policies for the recording of medicines. This is outstanding from April 2005. Timescale for action 07/05/07 2 YA20 13 (2) 04/04/07 3 YA39 24 (1)(a)(b) (3) It is required that an effective 07/05/07 quality assurance and monitoring system be implemented, based on seeking the views of service users. This is outstanding from April 2005. Mount Lodge DS0000021169.V307346.R01.S.doc Version 5.2 Page 24 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 Mount Lodge DS0000021169.V307346.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone Kent ME16 9NT 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 Mount Lodge DS0000021169.V307346.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. Re-publishing this information is in breach of the terms of use of that website. 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