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Inspection on 01/11/05 for Narborough Lodge

Also see our care home review for Narborough Lodge for more information

This inspection was carried out on 1st November 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The registered manager makes an excellent effort to maintain good standards of care in the home. Staff spoke positively about the approach to managing the home indicating that the approach promotes an open and inclusive atmosphere. The management team are committed to raising and maintaining good standards of care for the resident group based on the outcomes from inspection visits. The home is maintained to an acceptable standard creating a homely environment, some areas are still in need of updating and this is reflected in the plan of maintenance compiled by the manager. A choice of meals is evident; they are varied and well presented. Daily activities are varied, with all the residents being employed or in part time education; and residents spoken with, indicated that they are satisfied with the overall care given in the home. Medication is very well managed, care plans and risk assessments are completed accurately with a significant amount of detail in relation to each resident.

What has improved since the last inspection?

No areas were identified at this inspection.

What the care home could do better:

Quality assurance questionnaires could be developed, with completion being assisted by an advocate or person independent from the resident or staff group. The findings of these could then be included in the Service User Guide, which is circulated prior to residents taking up a place in the home. Hot water blending valves have not yet been fitted within the home, it would be advisable for this to be undertaken promptly to comply with health and safety regulations and ensure resident safety.

CARE HOME ADULTS 18-65 Narborough Lodge 504 Narborough Road Leicester Leicestershire LE3 2FU Lead Inspector Keith Williamson Unannounced Inspection 1st November 2005 04:00 Narborough Lodge DS0000057109.V261520.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Narborough Lodge DS0000057109.V261520.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Narborough Lodge DS0000057109.V261520.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Narborough Lodge Address 504 Narborough Road Leicester Leicestershire LE3 2FU 01628 826944 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) Narborough Lodge Limited Alison Richardson Care Home 6 Category(ies) of Learning disability (6), Mental disorder, registration, with number excluding learning disability or dementia (6) of places Narborough Lodge DS0000057109.V261520.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Registration condition Narborough Lodge Ltd is registered to only provide the service as outlined in their statement of Purpose/Service User Guide as agreed with the Commission for Social Care Inspection at the date of registration. 06/06/05 Date of last inspection Brief Description of the Service: Narborough Lodge is a newly registered small care home in a semi-detached property. It is registered for up to 6 adults with learning disability and mental disorder. All bedrooms provide single accommodation and are located on both the ground and first floor and are close to bathrooms. The home is situated on the Narborough Road, heading out towards Fosse Park Shopping Centre and is a 30-minute bus journey to the city centre. There is limited parking to the front of the home. Additional parking is available on the side street. There is a large garden to the rear that is managed by the service users with some support from the staff. There are plenty of in-house activities, which are run by an activities organiser. The home is comfortable with staff that are committed, and have a good relationship with each other and the service users. There is a stable staff team who are have completed or are in the process of completing their National Vocational Qualification awards. Narborough Lodge DS0000057109.V261520.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of the inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service users and their views of the service provided. The primary method of Inspection used was ‘case tracking’ which involves selecting clients and tracking the care they received through looking at their records, talking with them where possible, and looking at their accommodation. The inspection took place over one day, commenced at 12.00 am and was completed in 3 hours by one Inspector. An opportunity was taken to view the care plans and other records in detail. Two residents and two staff were spoken with on this visit. Resident questionnaires that were returned to the Inspector were included within the previous inspection report. The manager assisted with the Inspection, spending time with the Inspector discussing the management of the home. Overall the Inspector recognised the home, continues to function very well and provides a homely but secure environment for residents’. What the service does well: The registered manager makes an excellent effort to maintain good standards of care in the home. Staff spoke positively about the approach to managing the home indicating that the approach promotes an open and inclusive atmosphere. The management team are committed to raising and maintaining good standards of care for the resident group based on the outcomes from inspection visits. The home is maintained to an acceptable standard creating a homely environment, some areas are still in need of updating and this is reflected in the plan of maintenance compiled by the manager. A choice of meals is evident; they are varied and well presented. Daily activities are varied, with all the residents being employed or in part time education; and residents spoken with, indicated that they are satisfied with the overall care given in the home. Medication is very well managed, care plans and risk assessments are completed accurately with a significant amount of detail in relation to each resident. Narborough Lodge DS0000057109.V261520.R01.S.doc Version 5.0 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. Narborough Lodge DS0000057109.V261520.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Narborough Lodge DS0000057109.V261520.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 5. The assessment and admission process is detailed and effective, which enables the staff team to deliver appropriate care. EVIDENCE: The Statement of Purpose has yet to be reviewed, and have the issues recommended in the last inspection report included within. Needs assessments are completed on an individual basis, prior to admission to the home, these then feed directly into the main plan of care. The contract is presently reproduced in written form, and is adequate for the current purposes. Narborough Lodge DS0000057109.V261520.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9. Robust processes are in place to give residents the independence to make safe decisions. Choices are apparent in the home, providing residents’ with participation and fulfilment. EVIDENCE: A detailed inspection of two care plans indicated that aspects of the residents assessed care needs has been identified and recorded in the document. The care plan is then reviewed on a regular basis and changes made accordingly. Neither of the two residents interviewed could confirm that they understood and agreed their individual plan, though some plans are signed by the resident or a representative. Risk assessments are included in the care plans seen on the day. Both the care plans and risk assessments have good detailed information in setting out the actions staff members must take to meet residents’ assessed care needs. Staff showed a good understanding of the content in residents individual plans of care. Narborough Lodge DS0000057109.V261520.R01.S.doc Version 5.0 Page 10 Evidence of decision-making remains apparent, with residents being encouraged to participate appropriately in an open choice of daily living, education and financial expenditure. Narborough Lodge DS0000057109.V261520.R01.S.doc Version 5.0 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): 13 & 15. A range of appropriate community experiences and relationship choices are offered ensuring good quality care is delivered. EVIDENCE: Residents interviewed on the day showed an awareness of the facilities in the local community. One resident has a positive relationship with local law enforcement officers, so increasing his protection within the community. Contact between residents their families and other visitors is encouraged by staff supporting privacy within personal visiting, and assistance to visit others away from the home. Narborough Lodge DS0000057109.V261520.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): No standards within this group were inspected on this occasion. EVIDENCE: Narborough Lodge DS0000057109.V261520.R01.S.doc Version 5.0 Page 13 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): Residents are protected from abuse by robust adult protection procedures. EVIDENCE: Staff training is available to ensure residents are not placed at risk of abuse in the home, one member of staff showed a good knowledge of adult protection issues, however the other showed a poor knowledge of these issues and terminology. All staff should have periodic training on abuse and self-harm. Narborough Lodge DS0000057109.V261520.R01.S.doc Version 5.0 Page 14 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): No standards within this group were inspected on this occasion. EVIDENCE: Narborough Lodge DS0000057109.V261520.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35. A number of training courses are provided for staff ensuring an effective staff group. EVIDENCE: Evidence is apparent of the courses offered to all designations of staff in the home. Individual certificates are in evidence in staff files. Narborough Lodge DS0000057109.V261520.R01.S.doc Version 5.0 Page 16 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39 & 42. Residents and their representatives are consulted and involved in the running of the home. EVIDENCE: Effective quality monitoring systems are in place in the home. Questionnaires are issued periodically to a range of individuals who visit and support the home; the deputy manager stated the outcomes of these should be added at the next review of the Statement of Purpose and Service User Guide. The annual development plan for the home is in place. The blending valves recommended in the last report, are in place in the home, but have not yet been fitted; though the manager has put additional monitoring of residents in place to compensate until such times fitting can be arranged. Narborough Lodge DS0000057109.V261520.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X X 3 Standard No 22 23 Score X 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 3 14 X 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X X X X 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Narborough Lodge Score X X X x Standard No 37 38 39 40 41 42 43 Score X X 3 X X X x DS0000057109.V261520.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? No. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA1 Good Practice Recommendations It is recommended that full information on the locked door policy and alternative access to, and exit from the home be added to the Statement of Purpose and Service User Guide. It is recommended that the results from any questionnaires completed by residents or their representatives, be added to the Statement of Purpose and Service User Guide. It is recommended that the resident contract is produced in a pictorial format to enable a broader understanding of this document by the resident group. It is recommended that the “house rules” are produced in a pictorial format to enable a greater understanding of this document by all resident. It is strongly recommended the Multi Agency protocol for Vulnerable Adults is replaced in the home urgently. That the blending valves for the hot water system in the home are fitted promptly to ensure residents’ safety. DS0000057109.V261520.R01.S.doc Version 5.0 Page 19 2. YA1 3. 4. 5. 6. YA5 YA15 YA23 YA42 Narborough Lodge Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Narborough Lodge DS0000057109.V261520.R01.S.doc Version 5.0 Page 20 - 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!