Inspection on 08/08/05 for Narborough Lodge

This inspection was carried out on 8th August 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.

Other inspections for this house

Narborough Lodge 05/09/06

Narborough Lodge 01/11/05

Narborough Lodge 06/08/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Narborough Lodge 504 Narborough Road Leicester Leicestershire LE3 2FU Lead Inspector Keith Williamson Unannounced 8 August 2005 at 9.00am th 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. Narborough Lodge C51 S57109 Narborough Lodge V231213 080805 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Narborough Lodge Address 594 Narborough Road Leicester LE3 2FU 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) 01628 826944 0116 2827337 None Narborough Lodge Limited Alison Richardson Care Home 6 Category(ies) of MD Mental Disorder - 6 registration, with number LD - Learning Disability - 6 of places Narborough Lodge C51 S57109 Narborough Lodge V231213 080805 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: There are no additional conditions of registration. Date of last inspection 06-08-04 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 accomadation 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 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. Service users participate in entertainment within the community and social activities. Fifty per cent of the service users choose to attend the day centres whilst some have voluntary or paid employment. Some service users attend college to enhance their life and social skills. The service users are involved in the running of the home, they help with daily house routines and cooking. The Registered Manager has many years experience of managing a care home for people with a learning disability. The Registered Manager has completed the National Vocational Qualification level 4 – the Registered Managers Award. 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 the National Vocational Qualification award. Narborough Lodge C51 S57109 Narborough Lodge V231213 080805 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over one day, commenced at 9.00 am and was completed in 4 hours by one Inspector. An opportunity was taken to view the care plans and other records in detail. Three residents were spoken with on this visit, the comments made are included within this report; two staff were also spoken with. Six questionnaires were returned to the Inspector prior to the Inspection process, the comments enclosed shall also be included within this 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: What has improved since the last inspection? The registered manager has improved the general health and safety by completing the outstanding requirement with regard to automatic door closures. Both good practice recommendations have also been implemented. Narborough Lodge C51 S57109 Narborough Lodge V231213 080805 Stage 4.doc Version 1.30 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Narborough Lodge C51 S57109 Narborough Lodge V231213 080805 Stage 4.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 Narborough Lodge C51 S57109 Narborough Lodge V231213 080805 Stage 4.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, 2, 3 & 5. The admission process is good and the assessment process is detailed and effective, which enables the staff team to deliver appropriate care. EVIDENCE: Examination of the Statement of Purpose indicated that it accurately outlines the services provided in the home, however none of the three residents spoken with could indicate that the care is delivered according to what is written in the document. The contract is presently reproduced in written form, and is adequate for the current purposes. Communication methods are then employed where possible based on the service users skills of comprehension to give this information to residents. There is evidence in place to indicate the use of advocates within the home. Narborough Lodge C51 S57109 Narborough Lodge V231213 080805 Stage 4.doc Version 1.30 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 standard(s) 6, 7, 9 & 10. 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 three residents’ care plans indicated that all aspects of their assessed care needs has been identified and recorded on the document, which is reviewed on a regular basis. None of the three residents could indicate that they are satisfied that their assessed care needs are being taken care of. Evidence of additional information such as behavioural monitoring paperwork was in place, additional information from the Community Health Team workers is also evident in residents care plans and daily records. Risk is assessed appropriately and also reflected in the care plans seen on the day. Two of the three care plans and risk assessments seen supported by a detailed discussion with the registered manager indicated that the care plans have good information in setting out the actions staff members must take to meet residents’ assessed care needs. Evidence of decision-making is apparent, with residents being encouraged to participate in an open choice of daily living, education and financial expenditure. Narborough Lodge C51 S57109 Narborough Lodge V231213 080805 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 16 & 17. Good opportunities for residents to access work and educational facilities, maintain good community links and have choice concerning their daily lives. EVIDENCE: One resident spoken to indicated that this person is currently in employment. Supporting documentation substantiates that this person’s occupational needs are being met. Another two residents attend college five days per week, these residents’ daily recordings were seen, and indicated that their daily routine includes regular contact with relatives and friends. One resident stated, “I like to go shopping” indicating that this forms part of their ongoing routine. The discussion held with two residents and the registered manager indicated that meals are varied and wholesome and given to the residents according to their choice, which is aided by the use of a “pictorial” menu. Narborough Lodge C51 S57109 Narborough Lodge V231213 080805 Stage 4.doc Version 1.30 Page 11 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 & 20. Suitable processes are in place to meet residents’ hygiene and health care needs. EVIDENCE: The two residents spoken to indicated that support is given by the registered manager and staff to ensure that their hygiene care needs are fully met, which is recorded in both residents’ care plans and their daily care records. A detailed inspection of two residents’ care records indicated that healthcare professionals such as Community Nurses and General Practitioners form part of the care process. Two residents spoken with indicated that they access doctors and other professionals located in the community as part of their ongoing care. Discussion held with two residents and the registered manager indicated that no residents currently administer their own medication. The medication policy was seen and contains sufficient information for staff members’ guidance regarding monitoring residents when they take their medication. Narborough Lodge C51 S57109 Narborough Lodge V231213 080805 Stage 4.doc Version 1.30 Page 12 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) 22. Robust processes ensure that residents or their relatives can make complaints. EVIDENCE: A detailed examination of the written complaint process indicated that clear guidance is given to residents and their relatives on how to make a complaint. No residents spoken with gave any clear verbal responses on how to access the complaint process and whom they should contact to make a complaint, but support is in place for all residents to actively complain if required. Inspection of the internal complaints information revealed one internal complaint, which was recorded and dealt with satisfactorily. Narborough Lodge C51 S57109 Narborough Lodge V231213 080805 Stage 4.doc Version 1.30 Page 13 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, 25, 26 & 30. The home is comfortable, hygienic and pleasant in appearance, which creates a homely environment. EVIDENCE: A number of safety improvements have been made to the fire doors since the last inspection. Residents’ bedrooms are personalised and suit the needs of the individual users, some residents have light domestic duties and are encouraged to keep their own bedrooms tidy. Cleaning schedules are in place, and care staff cover the majority of the domestic tasks. Narborough Lodge C51 S57109 Narborough Lodge V231213 080805 Stage 4.doc Version 1.30 Page 14 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. The recruitment policies protect residents in the home. EVIDENCE: Staff files were viewed and have the appropriate pre recruitment information enclosed, to enable the protection of residents through safe employment practices. Narborough Lodge C51 S57109 Narborough Lodge V231213 080805 Stage 4.doc Version 1.30 Page 15 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) 42 The health and welfare of residents is protected by good management practices EVIDENCE: General improvements to health and safety have taken place with the introduction of automatic door closures, in the event of a fire. These and a number of other tests are performed periodically ensuring the safety of residents is maintained. Narborough Lodge C51 S57109 Narborough Lodge V231213 080805 Stage 4.doc Version 1.30 Page 16 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 3 3 3 x 3 Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 x x x 3 Standard No 11 12 13 14 15 16 17 3 3 x x x 3 3 Standard No 31 32 33 34 35 36 Score x x x 3 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Narborough Lodge Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x x x x x 3 x C51 S57109 Narborough Lodge V231213 080805 Stage 4.doc Version 1.30 Page 17 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 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. 2. 3. 4. 5. 6. 7. Refer to Standard 1 1 5 5 17 42 43 Good Practice Recommendations 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. That the results from any questionaires completed by residents or their representatives, be added to the Statement of Purpose and Service User Guide. That the resident contract is produced in a pictorial format to enable a broader understanding of this document by the resident group. That the bedroom number or explanation which bedroom has been alloted to a resident is added to the contract or individual placement agreement. That the temperature monitoring of food for residents, is fully inclusive and descriptive. That the blending valves for the hot water system in the home are fitted promptly to ensure resident safety. That the registered person commence sending a copy of their visits to the home to the CSCI. Narborough Lodge C51 S57109 Narborough Lodge V231213 080805 Stage 4.doc Version 1.30 Page 18 Commission for Social Care Inspection The Pavilions, 5 Smith Way Grove Park Enderby Leicestershire 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. 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