Inspection on 29/01/08 for New Lodge

This inspection was carried out on 29th January 2008.

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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

New Lodge 09/03/09

New Lodge 03/10/06

New Lodge 20/02/06

New Lodge 23/08/05

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 New Lodge 971 Lightwood Road Longton Stoke on Trent Staffordshire ST3 7NE Lead Inspector Wendy Jones Key Unannounced Inspection 29th & 30thJanuary 2008 10:40 New Lodge DS0000064018.V346482.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 New Lodge DS0000064018.V346482.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. New Lodge DS0000064018.V346482.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service New Lodge Address 971 Lightwood Road Longton Stoke on Trent Staffordshire ST3 7NE 01782 388370 01782 269187 stoke.enquiry@caretech-uk.com 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) Delam Care Ltd vacant post Care Home 4 Category(ies) of Learning disability (4) registration, with number of places New Lodge DS0000064018.V346482.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd October 2006 Brief Description of the Service: New Lodge is registered for four younger adults with learning disabilities. The home was commissioned specifically for the four current service users. The service users have complex needs that include autism, severe learning disability, challenging behaviour and physical disability. The home is located on the main road in a semi-rural location on the outskirts of a small village. The home is a spacious four bedroom detached house with a large front and a paved patio area at the rear. The home is set back from the road with parking facilities for staff and visitors. The home was generally well decorated in a domestic and homely manner whilst considering the needs of the service users. There are few facilities in the immediate area and the service users have their own transport that they fund that enables them to access a range of educational, social and leisure activities away from the home. The home provides single bedroom accommodation for all the service users. Three bedrooms are provided upstairs and one on the ground floor. The home is not suitable for permanent wheelchair users. The fees are not recorded in the Service User Guide. Prospective placing authorities, service users or their supporters should approach the provider for this information. New Lodge DS0000064018.V346482.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate, quality outcomes. This was a key inspection site visit of this service undertaken on 29 January 2008 and included formal feedback to the deputy manager and acting manager on 30 January 2008. In total the visit took approximately 09:00 hours. The purpose of this visit was to assess the services performance and to establish if it provides positive outcomes for the people who live there. The service provides care and accommodation for younger adults who have severe learning disabilities and may have additional difficulties such as physical disabilities limited verbal communication and may exhibit challenging behaviour. The visit included checking that the requirements and recommendations of the previous inspection visit of 04/10/2006, the serious concerns identified during that visit and the subsequent unannounced random visits of 16 January 2007 and 24 January 2007 have been acted upon. It also involved looking at information the service provides for prospective residents, their carers and any professionals; looking at information that the service provides to people who use the service to ensure that they understand the terms and conditions under which they have agreed to live at the home and the fees they should pay. Other information checked included assessments and care records, health and medication records; activity and records relating to the menu’s, finances, staff training and recruitment, complaints and compliments, fire safety and health and safety checks. The manager, her deputy, staff and residents were spoken to during the site visit, observations of care practice undertaken and a brief tour of the building was undertaken. Before the visit began, the service provided an assessment of its performance, in the form of an Annual Quality Assurance Assessment (AQAA). Surveys were sent out to residents, relatives, and staff and any professional that has involvement in the service. One GP survey has been returned but has not been completed. Two relative surveys have also been received. The main points from these surveys are included in this report. As a result of this visit the service will be issued with an improvement plan, which tells them what they must do to address any areas of concern we have identified. We require that they return it to us to show that they have acted upon all of things we have asked them to. New Lodge DS0000064018.V346482.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The Statement of Purpose and the service user guide should be reviewed to ensure that they are up to date and the fee range and cost of the service is included. The service should ensure that all care plans are regularly reviewed, that the person centred plans are completed and implemented and were possible the information is produced in a user-friendly format. Service users and their supporters should be fully involved with care planning and reviews. New Lodge DS0000064018.V346482.R01.S.doc Version 5.2 Page 7 Health action plans should be implemented and behavioural management strategies agreed and put into place to support those service users who may exhibit challenging behaviour. All incidents in the home that affect the well being of service users must be reported to us, and where appropriate, referrals made under safeguarding procedures. This ensures that the safety and protection of service users is paramount. The environment needs to be improved in a number of areas for the benefit of service users, the ground floor bathroom must be refurbished, and the first floor bathroom should be adapted to ensure it is usable. The lounge should be more homely and the planned programme of refurbishment continued. All staff must receive mandatory training and training specific to the needs of service users. Staff vacancies should be filled to ensure that the numbers of agency staff are reduced. This provides service users with consistency and continuity of care. The manager must apply to us to be registered as the care manager for the service. 9 requirements have been made as a result of this site visit and 2 have not been fully met from the previous site visit, as a result of this the service will be asked to complete an improvement plan, to provide evidence of compliance in these areas. A number of recommendations are also made to improve the standard of care provided to 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. The summary of this inspection report can be made available in other formats on request. New Lodge DS0000064018.V346482.R01.S.doc Version 5.2 Page 8 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 New Lodge DS0000064018.V346482.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 5 Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. People who may use the service will receive information about the nature, aims and objectives of the service but cannot be sure that the information provided is up to date. This means that they cannot make a properly informed decision about moving into the home. They can be sure from the information provided that their needs will be assessed prior to being offered a place at the home. EVIDENCE: The service has a statement of purpose and service user guide both need updating to reflect the changes in the management and staff team that have taken place since the last inspection. To take into account the changes in the contact details for us; to include the terms and conditions of residency and the fees charged by the service. Records show that both documents were last updated on 6th June 2006. The service user guide is in a user-friendly format using pictorial prompts as well as simple language. In a sample of a care file it was noted that a copy of the service user guide is available. The statement of purpose contains corporate aims and objectives but is not clear about the admission criteria for the unit itself. This should be clarified to ensure that prospective service users have the information needed to establish if the home is suitable to meet their needs. Relative’s surveys indicated that they sometimes or usually receive enough information about the home. New Lodge DS0000064018.V346482.R01.S.doc Version 5.2 Page 10 In the AQAA the manager has stated, “All new prospective clients, have an Assessment, we invite them to visit the home prior to a commencement date and to have a meal with other clients, this is time to meet other clients. New clients or their representative are made aware of their rights and responsibilities through the provision of a contract supplied by home and by the funding authority.” There have been no new admissions to the home since it opened 7 years ago but any prospective service user would have information about the nature of the service available to them taking into consideration all the above. New Lodge DS0000064018.V346482.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, and 9. Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. People who use the service can be sure that care plans are in place, that inform staff how their care needs should be met. But they cannot be sure that they are involved in the care plan development or review or that the format is user friendly. EVIDENCE: Since the last key inspection some work has been undertaken to look at Person centred approaches to care, a person centred plan (PCP) has been started but in the sample seen had not been completed. There is no evidence that any other work has been done towards completing this process, which is a shame. However the new management team have started to introduce support plans and other records to ensure that service user plans give a detailed account of how staff should provide support and it is also noted that risk assessments have recently been reviewed and updated. New Lodge DS0000064018.V346482.R01.S.doc Version 5.2 Page 12 Communication plans were identified at previous inspection visits as a necessary development, these have been completed dated 30.05.07 but have not been reviewed within the timescale stated on them, which is November 2007. There is some concern around how the service is managing the known challenging behaviour of one service user. Currently the outcome of this management strategy is for the individual to be relatively isolated from those service users who may be vulnerable. While the need to protect service users is to be applauded it is difficult to understand how this strategy is helping any of the service users at the home. It is understood that the new manager has contacted behavioural specialists for some support in this area. One relative in a survey, expressed concern about the vulnerability of their relative, this issue was looked at during this visit and is reported on separately in the Complaints and Protection section of this report. Another relative also expressed some concerns about levels of communication from the home. The manager should look at this issue and put into place plans to ensure that relatives are contacted on a regular basis and where possible share in the care of their relative. Risk assessments are in place and care files include daily records of events, including records of incidents and accidents the manager also does a monthly analysis of this information to determine any changes or increase in problems. This information is only useful if it affects the reduction of incidents in the home. In the information seen during this visit there appears to be a reduction in the number of incidents in the home. New Lodge DS0000064018.V346482.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. People who use the service, do have some opportunities to be involved in activities both in and out of the home, but this is limited and needs to be developed further to ensure that service users potential in this area is fully realised. EVIDENCE: Issues raised at the last two inspections continue to occur now, for example a service user has had a personal computer for over 12 months. At the last inspection it was broken and not in use. At this inspection it is locked in a bathroom because it can’t go in the bedroom due to problems with fitting new furniture, this issue has continued for some time and has yet to be adequately resolved. A resolution to this problem should be sought and an effective programme for the meaningful use of the computer put into place. New Lodge DS0000064018.V346482.R01.S.doc Version 5.2 Page 14 During this visit three service users went out in the home vehicle, one had a GP appointment, one went to Broom Street a specialist activity/occupational centre, and two of the service users went to a local shopping centre for a morning coffee. The other service user was engaged in cookery activities in the home on a 1:1 basis. In the afternoon all service users remained in the home, one was observed to occupy himself, another was engaged for a short period with a board game, and another was supported to look at a clothing catalogue with a member of staff. It is clear from this visit as at previous visits, that the service needs to look at the whole issue around occupation and recreational activities. The manager has also identified this as an area for development. Activity records show that the service does try to engage and include service users in a number of recreational and social opportunities, records show examples of meals out, trips in the vehicle shopping trips and local pub visits and walks. There is evidence that service users use community facilities and access ordinary services for example hairdressers etc. But the location of the home does limit the community participation of service users. It is reported that all service users have close contact with families with no restrictions placed upon visiting. A relative said, “The service sometimes meets the needs of relative and usually helps relatives to keep in touch. They usually keep me informed of important events.” The manager stated that she has made arrangements to meet with all the relatives to discuss care or any other concerns they may have.” Another relative said, “They always gives support to relatives. Always meet the differing needs of people. Always support people to live the life they choose, as much as possible.” A four weekly menu plan is available, but needs to be developed to ensure that service users are supported to make real choices about the meals they have. Future developments include pictorial menus and photos of meals so that residents can help to plan menus for the following week and actively participate in this activity. Some service users were observed freely accessing food and drink from the kitchen and fridge, for others some restriction are necessary due to identified risks during times when meals are being cooked. The service operates a staggered meal-time, this is again in response to the behavioural needs of service users. New Lodge DS0000064018.V346482.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. People who use the service can be sure that their health and personal care needs are known and understood by the staff and can be confident that they will be supported to receive appropriate health care. But further work is needed to involve community based specialist health professionals in health planning and promotion. EVIDENCE: Staff were observed to be sensitive in their approach to the care and personal care needs of service users throughout this visit. Staff are knowledgeable about the health needs of service users and relatives confirmed that they are usually kept informed of important events. The new manager is a registered nurse in the learning disability field and demonstrated a good knowledge and understanding of the needs of the service user group. Health care needs are identified in each of the care records, with evidence that contact is made with health professionals where necessary. Health Action Plans have yet to be implemented. Although the paper work is available in the home. Staff should also receive training in this. Advice was given about New Lodge DS0000064018.V346482.R01.S.doc Version 5.2 Page 16 accessing the Community health care facilitators, who are employed locally and are available to offer guidance in this area. The new manager stated that she has contacted behavioural specialist services for support in meeting the needs of service users, and is keen to liaise with other health professionals to ensure that all service users health needs are properly met. This is reassuring as it is an area identified at previous inspections that needed further development for the benefit of service users. Adaptations and specialist equipment are provided for those service users who’s require them Health records show that health needs including weight and dietary intake is monitored regularly, and also shows that service users receive regular preventative health appointments, including dental, chiropody, and specialist appointments with psychiatrists and neurologists. The AQAA indicates that every service user has a 6 monthly medication review and that all senior staff have received training in the administration of medication, it also states that the service has medication policies and procedures in place. The evidence of this visit is that the service has robust systems in place for the management and administration of medication and has addressed the areas identified for action at previous inspection site visits. None of the current service user group self medicates. New Lodge DS0000064018.V346482.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. People who use the service can be sure that they will be supported if concerns are identified, but the service should be more open and proactive in reporting incidents to the appropriate authorities to ensure that all issues are looked into properly. This will ensure that service users are protected from abuse and their rights protected. EVIDENCE: The home has a complaints procedure in place. The procedure is in a userfriendly format, but the service users rely on carers and their supporters to raise concerns on their behalf. Relatives said in their surveys, “I know how to make a complaint. The service always responds appropriately if concerns have been raised.” “Usually respond to concerns raised appropriately, but they take their time.” The AQAA states, “ We promote the individuals safety in their own home. Due to the clients ability in not been capable in expressing their views, we do encourage family members to express their views and concerns which are listened to and acted on appropriately. The home as a complaints procedure displayed in the downstairs hall way and in the office. There is also a pictorial version present. Procedures are in place to protect residents from abuse. We deliver training in adult protection.” Staff confirmed that they have received training in recognising and reporting abuse. And adult protection issues. New Lodge DS0000064018.V346482.R01.S.doc Version 5.2 Page 18 We have not received any complaints about the service, the records in the home show that they have not received any formal complaints, but have received two compliments about the service they provide. The manager identified that there are concerns about the vulnerabilty of two service users from the behaviour of another, she stated that this issue is being closely monitored and the incidents have reduced. Records show that there have been issues raised at reviews by the families of service users. Additional staffing has been provided at night and increased supervsion on a 1;1 basis has been provided. The manager stated that referalls have been made to independent advocacy services to ensure that service user rights are promoted when these matters are discussed. We have not received any notification of these incidents and do require that service inform us of “any event that affects the welfare of service users.” This must be addressed. The service should also make referrals under safeguarding procedures if the well being and safety of any service user is compromised. New Lodge DS0000064018.V346482.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27 and 30. Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. People who use the service have a home that is in keeping with other residential properties in the area and generally enjoy an environment that meets their needs, but further work is necessary to ensure that the home is comfortable, well presented and well maintained. The bathing facilities must be improved for the benefit of service users. EVIDENCE: The AQAA states, “ New Lodge is a detached house situated in a rural area, five minutes walk to the country side. We provide a home that is a safe enviroment, we offer each client a room of their own decorated to their own requirements which meets the needs of the clients. The house has one large lounge where clients can enjoy watching T.V. and enjoy watching DVD’s and one large fitted kitchen where clients can help to prepare meals. At the front of the house we have a car park for approximately six cars, a large lawn that has a trampoline for clients to use supervised by a member of staff. At the back we have a patio with table and chairs, this is a paved area. All Clients are New Lodge DS0000064018.V346482.R01.S.doc Version 5.2 Page 20 encouraged to personalise their own bedroom, if they would like to bring any personalised furniture this we encourage. One bedroom as an en-suite with a toilet, sink and a shower.” This site visit did not include a detailed environmental inspection but there is evidence that the service needs to develop the home further. Some work has been done since the last inspection this includes one service user having new bedroom furniture fitted, a new TV has been purchased for the lounge, and the hall, landing, and kitchen have been redecorated also pictures have been put on walls to make the home more homely for servie users. The manager stated that there are plans to fit a new kitchen in the summer and they are considering the development of a sensory area off the main lounge. Areas identified for action during this visit include the ground floor bathroom, this area is particularly disappointing, stark and unwelcoming it would benefit from up grading. The lounge is open plan and quite spacious, but does not feel homely. The first floor bathroom has been identified as another area that requires upgrading, due to the style of the bath, the staff have identified a potential manual handling risk. Also as it is not being used, other items are being stored in the bathroom, and this area does not have smoke detection fitted, advice should be sought from the fire safety officer about this. The manager was also looking into a risk area associated with the garage, and was in discussion with the company to address this, there is currently no risk associated with service users in this area. All bedrooms are for single occupancy, all have wash hand basins, and the doors are fitted with locks, the ground floor bedroom has an en-suite facility. A relative said in a survey, “They provide a nice environment.” New Lodge DS0000064018.V346482.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36. Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. People who use the service can be sure that they are protected by robust recruitment procedures and practice, but cannot be sure that all staff are qualified or have received mandatory training. This potentially leaves them at risk. EVIDENCE: Staffing levels are reported to be 4 during the early shift and three during the late afternoon and evening, with two waking night staff. The manager hours are additional to these hours. A sample of staff rosters for an 11-day period confirmed this, but 9 shifts had been filled by agency staff, to ensure that these levels are maintained. Since the last inspection there has been a change in the management of the service. It was also reported that a recent recruitment drive had been successful; 2 new care workers who were on duty during this site visit. There are currently staff vacancies for 2 nights per week. New Lodge DS0000064018.V346482.R01.S.doc Version 5.2 Page 22 A check of recruitment information shows that relevant checks have been carried out on individuals, prior to them commencing work in the home. The manager confirmed that new staff do not start to work until appropriate checks have been carried out. The company maintains the POVA and CRB records at its headquarters in Hertfordshire and the company’s compliance with these checks is undertaken centrally by the CSCI. A new member of staff confirmed that these checks had been carried out and stated that her induction had been satisfactory. There are some gaps in the training records that must be addressed, these relate to mandatory training such as infection control, manual handling, vulnerable adults, and basic food hygiene. A number of staff have yet to attend training sessions in autism this was an issue identified at the previous inspection. Information in the AQAA says, “80 of care staff have safe food handling training and 5 of the care staff have a National Vocational Qualification (NVQ) with 6 others working towards level 2.” This is an improvement since the last key inspection, but it is also recognised that since the AQAA has been completed some staff changes have ocurred and this information may not know be accurate. The service operates a key worker system and has 3 team leaders allocated to lead the shifts along with the deputy and manager. Regular team meetings are arranged records show that these have been monthly recently, showing dates of 18 December 2007 and 9th January 2008. Staff supervision has taken place but due to changes in the management team this needs to be re established on a regular basis. Relatives said, “ Care staff do their best, but I think their role is more like wardens.” “I would hope that the staff have the experience and skills to look after people properly.” New Lodge DS0000064018.V346482.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42, 43. Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. People who use the service can be sure that the manager of the home has experience of providing care for people with a learning disability, but she has not yet been approved as the registered manager. Quality monitoring is in place but needs to be developed further so the service users can be sure that the service is continually improving. EVIDENCE: The manager is a registered nurse in the specialist field of Learning Disability services. She has been newly recruited to the service and has yet to be approved by us as a fit person to manage the service. The deputy manager is also new. The AQAA was completed by the previous manager and provided all the information asked for. New Lodge DS0000064018.V346482.R01.S.doc Version 5.2 Page 24 Information available in training records identified gaps; it is advised that all staff must receive mandatory training, manual handling, infection control, vulnerable adults, and basic food hygiene. The deputy manager is taking a lead role in co-ordinating staff training. Records show that fire safety checks are carried out regularly this is confirmed from the AQAA. A fire safety risk assessment was last reviewed on 19/12/06; a further review should be undertaken. Fire training records are up to date and the service has an emergency contingency plan for the service and the individual in the event of a serious fire. Fire drills have been carried out regularly with day staff, but the records show that night staff drills have not been as frequent as recommended. The manager and a member of staff allocated responsibility for this stated that a more recent night staff drill had been carried out, but could not find the records to confirm this. Service users finances are managed on their behalf either by the home or by the individuals’ families. Records show that the service has good systems in place for recording, checking and auditing. Two staff sign for each transaction made, the reason for the transaction is noted and receipts are numbered and retained. In a random sample of 2 records, both balances matched the amount of money held on behalf of the resident. The manager (as stated previously) carries out monthly audits of the service to assess the continuity and quality of care provided. In addition a representative on behalf of the organisation visits the home monthly to monitor the conduct of the service. Reports of these visits are available in the home. This information is used to inform an annual report on the performance of the home and to determine a development plan. This is an area that wasn’t discussed in detail during this site visit as the new manager’s time has been committed to other areas since her arrival. It is hoped that at the next visit, the service will be able to show how it has progressed in the last 12 months. New Lodge DS0000064018.V346482.R01.S.doc Version 5.2 Page 25 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 2 2 3 3 x 4 x 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 1 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 2 33 x 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 x 2 x LIFESTYLES Standard No Score 11 x 12 2 13 2 14 x 15 2 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 3 x 2 x 2 x x 3 3 New Lodge DS0000064018.V346482.R01.S.doc Version 5.2 Page 26 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 YA1 Regulation 5(b) Requirement The service user guide must include the fee range and the cost of the service. To ensure that the plan to provide computer activities for one resident is implemented. (previous timescale not met) Timescale for action 29/04/08 2. YA12 12(1)(b) 29/04/08 3. YA14 16(2)(m)&(n) To ensure that residents are provided with a range of leisure activities both in and out of the home. (previous timescale not met) 23(2) The registered person must provide bathing and toilet facilities that are well maintained and appropriate for service users. The registered person must ensure that all notifications of incidents affecting the wellbeing and welfare of service user are reported to us. 29/04/08 4. YA27 29/04/08 5. YA23 37 29/04/08 New Lodge DS0000064018.V346482.R01.S.doc Version 5.2 Page 27 6. YA32 18(1)(c) To ensure that staff are provided with the training to undertake their role including autism and mandatory training. 29/04/08 7. YA33 18(1)(a) The registered person must 29/04/08 ensure that staff vacancies are filled to reduce the use of agency staff in maintaining satisfactory staff levels. That the new manager applies for registration with the Commission. The registered person must ensure that all staff have been involved in regular fire drills. 29/04/08 8. YA35 9 9. YA42 23(4)(e) 29/04/08 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. Refer to Standard YA1 YA24 YA6 Good Practice Recommendations The Statement of Purpose and Service User Guide should be reviewed to ensure that they are up to date. To look at methods that would make the accommodation more homely To continue to develop support plans based on Person centred planning and on current good practice and investigate methods of involving service users in care planning and review where possible. To continue to look at ways of developing communication methods and providing more user-friendly information e.g. DS0000064018.V346482.R01.S.doc Version 5.2 Page 28 4. YA7 New Lodge complaints procedure, menu planning. 5. YA9 To continue to develop risk assessments and behavioural management strategies based on current good practice for people with a learning disability that display challenging behaviours. In conjunction with specialist health services. To investigate appropriate fulfilling activities for residents, both in and out of the home. To further develop the system for reviewing and monitoring the service. To re establish the regular sessions of staff supervision. To continue with the programme of refurbishment that has been started. 6. 7. YA12 YA36 8. 9. YA36 YA24 New Lodge DS0000064018.V346482.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI New Lodge DS0000064018.V346482.R01.S.doc Version 5.2 Page 30 - 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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