CARE HOME ADULTS 18-65
Ormsby Lodge 1 Ormsby Road Southsea Portsmouth Hampshire PO5 2AL Lead Inspector
Christine Hemmens Unannounced Inspection 13 March 2006 11:00
th Ormsby Lodge DS0000011717.V253369.R01.S.doc Version 5.1 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 Ormsby Lodge DS0000011717.V253369.R01.S.doc Version 5.1 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. Ormsby Lodge DS0000011717.V253369.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Ormsby Lodge Address 1 Ormsby Road Southsea Portsmouth Hampshire PO5 2AL 023 9273 8752 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) Mr David Ernest Clarke Mrs Ninfa Clarke Miss Charlene Elizabeth Holman Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Ormsby Lodge DS0000011717.V253369.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Service users in the category LD are not to be admitted under the age of 18 years 14th June 2005 Date of last inspection Brief Description of the Service: Ormsby Lodge is a residential service providing care and support to twelve adults who have learning disabilities and complex behavioural needs. Ormsby Lodge is owned by Mr and Mrs Clarke who also own another residential service and a separate day service for service users with complex learning disabilities. Ormsby Lodge is a large period house set in a street of similar properties in a central location in Southsea. The house is set out over four storeys, the basement is used for storage and the service users accommodation is on the other three floors. The top floor has a small semi self-contained flat with a double bedroom and a single room, this can accommodate up to three service users who need limited support. There are further bedrooms on the first floor, two of which are doubles and there are four single rooms on this floor. There is one ground floor bedroom. The service does not accommodate people with physical disabilities or nursing needs. Service users are supported to use local amenities, which are a short walk away. Ormsby Lodge DS0000011717.V253369.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the second unannounced visit made to the home in twelve months. The inspector on this occasion did not meet with residents, however comment cards were left and the registered manager was requested to share and assist residents to complete the comment cards. The registered manager and Mr Clarke assisted the inspector. The purpose of the visit was to review requirements issued following the previous visit to the home, review standards not considered on the previous occasion and view the home. The outcome of this visit to the home was very positive and Mr Clarke, his manager and staff must be congratulated for the hard work they have undertaken to achieve required standards. Please read this report in conjunction with the previous inspection report undertaken on the 14th June 2005. What the service does well:
The home has done very well to meet all the requirements issued following the last visit to the home. Over the last eighteen months there has been a significant improvement in meeting requirements and standards. The home is especially very good at adopting a person centred approach and providing the residents with opportunities to develop and maintain skills and experience new activities. Discussion took place at the time of the visit regarding a resident whose desire is to access employment. The manager and Mr Clarke stated they were looking into this for the resident. The home ensures residents have a say in what they want to eat, at the same time guiding them to eat healthily. Specialist advice is sought for those who have dietary requirements. The home does well to listen and seek the views of the residents and assist them to express their concerns. The home holds regular meetings with the residents collectively to jointly seek their views, provide information and discuss topical issues such as menu planning. The staff also meet individually with the residents to review their personal plans. The residents are supported to make complaints with the assistance of staff and an accessible complaints procedure. The home has recently undertaken a comprehensive quality questionnaire, which has sought the views of the residents and their families. The home and its staff do well to provide an environment that is welcoming, decorated and furnished to a high standard and clean. As far as feasibly
Ormsby Lodge DS0000011717.V253369.R01.S.doc Version 5.1 Page 6 possible the environment is made safe for the residents and staff. The home is spacious, bright and airy and provides ample communal and individual living space to allow residents to socialise or spend time on their own if they wish. The home undertakes a robust recruitment procedure to safeguard the residents from harm. The home has done especially well to quality audit the service and seek the views of the residents and their relatives and self evaluate the service it provides. Ormsby Lodge has a manager who demonstrates commitment, enthusiasm, very good knowledge of the residents and has good values, which provides a good role model for the staff team. 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. Ormsby Lodge DS0000011717.V253369.R01.S.doc Version 5.1 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 Ormsby Lodge DS0000011717.V253369.R01.S.doc Version 5.1 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): 5 The home does well to provide each resident or their representative with information on the terms and conditions of their residency. EVIDENCE: The home has under taken a lengthy process to develop a contract of terms and conditions that is easy to read and reflects the service, accommodation and rights of the residents’ whilst living at Ormsby Lodge. Residents have been issued with a contract that has either been signed by them or a representative. Following the last visit to the home Mr Clarke was requested to obtain three signatures for the contracts not signed. Mr Clarke provided evidence that health had on numerous occasions had tried to do to get signatures from the residents representative. All but one of the contracts have now been signed. It was agreed at the time of the visit that the no further action would be taken as Mr Clarke had demonstrated he had done all he can to obtain the signature. Ormsby Lodge DS0000011717.V253369.R01.S.doc Version 5.1 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 and 9 The home does very well to reflect the residents’ individual needs, wishes and desires in their personal plans using a person centred approach, and ensures associated risks to individual residents are identified and minimised. However the home must consider how it will demonstrate that it monitors and evaluates outcomes for the residents. EVIDENCE: The inspector, the manager and Mr Clarke spoke at length of the changing needs of two residents who have lived at Ormsby Lodge for many years. Unfortunately one resident’s needs had changed so significantly that following reviews and input from other agencies it was agreed they could no longer support the individual. The inspector viewed the person centred plan of the other resident, this clearly detailed the individual’ specific routines, likes, dislikes, interests and hobbies and clear support plans to assist with daily living and personal care. There was evidence of the plans being reviewed to reflect the resident’s current changing needs. This demonstrates that the manager and staff are clearly addressing residents’ needs in the way that they wish and to minimise potential risks.
Ormsby Lodge DS0000011717.V253369.R01.S.doc Version 5.1 Page 10 However the manager needs to consider how the home will monitor and evaluate the residents’ person centred plans to demonstrate that the residents’ wishes and desires are being met. The manager produced evidence that the requirement to ensure risk management plans link to intervention plans has been met. The inspector viewed the intervention plans and risk management plans for one resident, these had been completed with support and agreement from the specialist community health care team and have been clearly written and detailed to provide staff with appropriate guidance. The manager and her staff have done very well to complete detailed and comprehensive risk assessments on all the residents living at Ormsby Lodge, these include all aspects of the residents’ daily lives including personal care, daily activity and community access. Risk assessments are reviewed and new ones developed when the needs of the residents change. This was evidenced in the personal plans and for a resident who had recently suffered a serious injury. Ormsby Lodge DS0000011717.V253369.R01.S.doc Version 5.1 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): 17 The home offers residents a healthy well balanced diet, where specific dietary needs are catered for. EVIDENCE: The manager and Mr Clarke demonstrated through discussion that they are aware of the importance to ensure that the residents receive a well balanced diet whilst having an in put into the menu planning and choosing what they would like to eat. The residents have three meals a day and have access to drinks and snacks throughout the day if they wish. The home is split into two, where residents who require limited support live in a small self contained flat at the top of the house and those needing more support have access to the rest of the home. The s=residents who require limited support meet weekly and discuss and plan the menu for the week. This evidenced in recorded minutes of their meetings. This seen as good practice. Residents have an opportunity to choose what they would like to eat. Choices observed in the meeting minutes appeared well balanced. The manager stated that staff do on occasions advise on healthy options and encourage those with specific dietary needs to try a healthy option such as fruit and yoghurts. Those
Ormsby Lodge DS0000011717.V253369.R01.S.doc Version 5.1 Page 12 residents with specific dietary requirements are closely monitored and access specialist services such as diabetic nurses and consultants. Ormsby Lodge DS0000011717.V253369.R01.S.doc Version 5.1 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 The home does well to support residents in the way they prefer using a person centred approach EVIDENCE: Individual personal plans demonstrate that residents are supported in the way they wish and this is reviewed. This `was confirmed by viewing a residents personal plan and discussion with the manager and Mr Clarke. Ormsby Lodge DS0000011717.V253369.R01.S.doc Version 5.1 Page 14 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 The home does well to ensure the residents are informed of how they can make a complaint if they are unhappy. EVIDENCE: The home demonstrated at the previous visit to the home that it uses various skills and techniques to judge how the residents’ are feeling and how they are proactive in ensuring residents are supported to express their feelings safely. In addition to the specialised techniques the home uses the home has produced a very good accessible complaints procedure, using all forms of communication, from pictures, written word and Makaton symbols. The home has also produced the complaints procedure on audiotape. The complaints procedure provides clear and specific detail on what the resident can do if they are unhappy and wish to make a complaint, the process, how long and who else they can speak with if they are not happy with how the home has dealt with their concern. Unfortunately the inspector did not have an opportunity to test the procedure out with the residents, however comment cards were left with the manager whereby the residents can state if they know how and who to complain to. Ormsby Lodge DS0000011717.V253369.R01.S.doc Version 5.1 Page 15 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 The home does well to provide a comfortable, welcoming and clean environment to live. EVIDENCE: Ormsby Lodge is a three-story home built in 1840, it is an impressive large building which still has some of its original features. The home is spacious and kept very clean and tidy. Bedroom facilities are provided over three floors, the third floor for more independent residents who are supported to maintain and develop daily living skills with separate kitchen and bathroom facilities. Fifty percent of the residents have their own room, however there is evidence that suggests there is agreement and a wish to share by others. All the bedrooms are spacious very clean and personalised. The home has a large communal kitchen, separate lounge and dining room. There are amble toilet and bathroom facilities over all floors. One bathroom has recently been redecorated and re designed to accommodate a residents changing physical needs. The inspector noted that all bathroom areas again to be very clean, however one toilet seat in an en suite was very worn and
Ormsby Lodge DS0000011717.V253369.R01.S.doc Version 5.1 Page 16 unsightly. Mr Clarke informed the inspector that it would be changed the same day. The home has two cleaners who have worked in the home twelve and eight years respectively, both ladies appeared to be happy in the work and the cleanliness of the home is a reflection of their hard work. On the morning of the visit both cleaners were working very hard, Mr Clarke stated the home is thoroughly cleaned and tidied on a Monday, as there are no cleaners over the weekend. A good open and relaxed rapport was observed between the staff members and the owner Mr Clarke. The inspector was informed that both members of staff had received training in infection control, health and safety corrosive substances hazardous to health (COSSH) and moving and handling. This is seen as good practice as it is important to ensure ancillary staff are respected and provided with the same training and support as care staff. Ormsby Lodge DS0000011717.V253369.R01.S.doc Version 5.1 Page 17 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): 34 The home undertakes a robust recruitment procedure to support and protect the residents. Evidence Following the previous visit to the home Mr Clarke was required to ensure a thorough recruitment procedure is followed and ensure all checks are in place and credible. References for the member of staff in question have now been checked and two credible references are in place. The inspector viewed the recruitment documents for a newly employed member of staff and found these to demonstrate the home has undertaken a thorough recruitment process including evidence that all checks such as Criminal Record Bureau Check (CRB) and Protection of Vulnerable Adult (POVA) are in place. EVIDENCE: Ormsby Lodge DS0000011717.V253369.R01.S.doc Version 5.1 Page 18 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 The residents benefit from a well run home that respects and listens to their views and as far as feasibly possible provides them with a safe place to live, however the home must ensure all checks on fire safety equipment are regularly undertaken. EVIDENCE: The registered manager has recently returned to work following a long absence, in her absence the home continued to develop and improve the service it provides to the residents, however the home will benefit from the experience and knowledge of the manager. Miss Holman informed the inspector that it was early days into her return but demonstrated that she was picking up where she left off and was eager to get into the swing of things again. Miss Holman informed the inspector that her return was well recieved by the residents who appeared to be pleased that she was back, however the first couple of months would be familiarising herself with the changes and getting to know the residents again. The manager demonstrates very good values and a good understanding of the complex needs of the residents. Miss
Ormsby Lodge DS0000011717.V253369.R01.S.doc Version 5.1 Page 19 Holman must now get back on track to complete her registered managers award. The home demonstrates that it values the views of the residents and their families, it has recently undertaken a quality review and involved the residents and their representatives in quality auditing the service by completing questionnaires. The inspector saw evidence of this and other forms of quality auditing that take place on a regular basis in the home. The inspector was provided with an action plan from the previous inspection that detailed the actions and proposed actions to improve and develop the service in all areas of the homes practice, including person centred planning, training for staff and restrictive physical intervention. The manager provided evidence that regular management and team meetings take place to evaluate outcomes. Mr Clarke and the manager spoke at length at the stage they are at with collating all the information gathered from the questionnaires and are now seriously debating and discussing how this information can be transferred to reflect the residents and their families views. The home generally provides a safe place for the residents to live, the home considers the health and safety of the residents and staff, staff are trained in health and safety, moving and handling, fire safety, food hygiene and infection control. The inspector viewed service certificates that demonstrated that appropriate and regular checks are made on fire appliances, however on viewing fire records the inspector established that the manager had not undertaken a fire check on fire call points for two weeks and monthly visual checks on fire fighting equipment. The manager agreed that this was an oversight on her part and would ensure that it didn’t happen again, the manager competently demonstrated that she knew how and what to look for when checking fire extinguishers. The inspector was informed that the boiler was due an annual check the same week of the inspection, however certificates were not available to view as the manager was unable to locate them. The manager was advised that all documents and corticated pertaining to the home utilities must be available at all times to view. It was agreed that this would not be made a requirement on this occasion. Ormsby Lodge DS0000011717.V253369.R01.S.doc Version 5.1 Page 20 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 X 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 X 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 X 33 3 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 X X 3 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 X X X 3 X 3 X X 2 X Ormsby Lodge DS0000011717.V253369.R01.S.doc Version 5.1 Page 21 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 YA42 Regulation Requirement Timescale for action 31/03/06 23(4)(c)(v) The registered manager must ensure regular checks are carried out on fire call points and fire fighting equipment. 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 YA16YA6 Good Practice Recommendations The registered manager is advised to monitor and evaluate the outcome of the residents’ personal plans to demonstrate that dreams and desires are being met and continued. Ormsby Lodge DS0000011717.V253369.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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