Inspection on 09/02/05 for Park Lodge

Care Homes For Adults (18 ­ 65)Park Lodge17 Stoney Street Burnley Lancashire BB11 3PTUnannounced Inspection9th February 2005 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Park Lodge Address 17 Stoney Street, Burnley, Lancashire, BB11 3PT Email address Tel No: 01282 458051 Fax No:Name of registered provider(s)/company (if applicable) Mr Joseph Serge Zephir Mrs Linda Joyce Zephir Name of registered manager (if applicable) Mrs Sarah Casey Type of registration Care Home No. of places registered (if applicable) 2Category(ies) of registration, with (number of places) Learning disability (2) Registration number F070000240 Date first registered 30th July 2002 Was the home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 3rd February 2005 YES NO 21/07/04 If Yes refer to Part CPark LodgePage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 39th, 10th February 2005 02:30 pm Mrs Marie DickinsonID Code088256Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionMRS SARAH CASEY N HANNSPark LodgePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards for Care Homes for Adults (18 ­ 65) 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: D.1. D.2. D.3. Compliance with Conditions ( if applicable) Providers Response Providers Comments Action Plan Providers AgreementPark LodgePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 as amended. This document summarises the inspection findings of the CSCI in respect of Park Lodge. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Adults (18-65) published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates.Park LodgePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Park Lodge Stoney Street is a small terraced house, situated within a short walking distance to Burnley town, and is in keeping with the neighbourhood. The home is registered with the Commission for Social Care Inspection to provide personal care and accommodation for two people with a learning disability. The home is owned by Mr and Mrs Zephir and managed by Sarah Casey. It was purchased specifically for two service users to live within the community with the support of the care staff. It was first registered under the Registered Homes Act 1984, and is classed as a pre existing registration under the Care Standards Act 2000. There are four homes in the scheme. Park House accommodates two service users with mild learning disabilities who for whatever reason require additional support in everyday living. Person centred care planning was used for service users, to enable them to have control in their lives. Accommodation offered was in two single bedrooms, and the home was domestic in scale. There was a lounge/dining room, bathroom and kitchen. The home was decorated and furnished to a very good standard. The home provided staff support for service users enabling them to actively participate in the management processes of running the home.Park LodgePage 5 PART ASUMMARY OF INSPECTION FINDINGSInspectors Summary (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) This is the second statutory inspection carried out at Park Lodge Stoney Street on the 9th & 10th February 2005. The Inspection was unannounced. The Inspectors main focus was on the service users in the home and also on the newly appointed manager Sarah Casey. There had been no new admissions since the last inspection. The Inspector talked to both service users to evaluate how their views were considered that affected their quality of life. An Inspector called to visit the people who lived at Park Lodge Stoney Street. The Inspector was called Marie Dickinson. Marie had visited before and she could remember both of the people who lived there. Marie talked to them and they told her what it was like living in the home and about the things they did. Marie talked to the manager Sarah and to Nicky a care staff. CHOICE OF HOME. STANDARD Standards 1-5 1 standard was assessed and met. Full compliance for all standards had been noted during the previous inspection. There had been no new admissions. A service user guide was available to potential service users in a format that considered their capacity for understanding. The admission protocol followed, encouraged service user involvement. Assessment, introductory visits and short stays would establish if an admission would be appropriate for the service users involved. Staff training and staffing levels had been considered. There was evidence of continuing training. There were no new people living at Park Lodge Stoney Street. Staff were always at the home to care for the people who lived there. INDIVIDUAL NEEDS AND CHOICES Standards 6-17 9 of 12 standards were assessed and met. 1 standard was commended. The Inspector did not look at service users care plans, but talked to both service users about care planning and their understanding of what this meant. It was evidenced care planning continued to be of a high standard, where service users assessed needs were considered. Reviews had been carried out, and the Inspector commended the home for maintaining a high standard evidenced during the last inspection. Staff supported service users in day-today living. Service users had a copy of their own policies and procedures. They had meetings and could be involved in the selection and appraisal of staff. Responsible risk taking was defined during the last inspection and best practice noted in risk management. There was evidence that service users rights were respected. Service users had weekly planners for various activities they had. Staff support was evident with flexible working to accommodate this. The service user had enjoyed Christmas with family and friends. The manager and staff on duty gave the Inspector privacy during the inspection to talk to the service users present. The people who lived at Park Lodge Stoney Street told Marie they continued doing all the things they liked. Staff were helpful and sometimes offered them advice if they were unsure what they should do. They went to town shopping and out to different places. Sometimes staff went with them. They had enjoyed Christmas. One person told Marie she had been busy working. Park Lodge Page 6 PERSONAL AND HEALTHCARE SUPPORT Standards 18-21 2 of 4 standards was assessed and met. The home operated a key worker system to support service users with personal and individual needs. The service users were happy with their key worker. There was evidence of healthcare management. Both service users informed the Inspector they had regular healthcare checks. The people at the home told Marie they had regular visits to the dentist. They could visit their doctor when they were not well. CONCERNS COMPLAINTS AND PROTECTION Standards 22-23 All standards were assessed and met. Service users had been given a complaint procedure to use in the home. It was in a userfriendly format. House meetings were regular and both service users agreed on outcomes. There were policies and procedures in the home that covered all types of abuse. Service users had been given an illustrated guideline on how to identify abuse, and what to do in the event of an abusive situation both inside and outside the home. Both people living in the home told Marie they could talk to the staff or Sarah who was their new manager if they had any problems. They also had house meetings every week to discuss what they wanted. ENVIRONMENT Standards 24-30 l standards were assessed and met. Park Lodge Stoney Street is a small two bed roomed mid terraced property located close to Burnley town centre. The home was tastefully decorated, furnished and fitted to a very good domestic style standard. Bedrooms were furnished and decorated to service users own needs and choice. The home was very clean. Both people living at Park Lodge told Marie they liked their home. It had everything in they needed. They both looked after it and shared the housework and cooking. Marie said they kept their home very clean. STAFFING Standards 31-36 2 of 6 standards were assessed and met. 1 standard was commended. All standards were assessed during the previous inspection and had been met. The Home was adequately staffed during the inspection. The deployment of staff had been co-ordinated to take into account peak time activity, and the presenting needs of service users. Recruitment procedures were based on equal opportunities. Service users views were actively sought in the selection of staff. Park Lodge was commended for the level of support and empowerment given to service users in selection and appraisal of staff. Sarah the manager told Marie the people who live in the home helped choose staff. Staff worked every day and night including Saturday and Sunday. The staff called at the home to help when the people living there needed help.CONDUCT AND MANAGEMENT OF THE HOME Standards 37-43 Park LodgePage 7 2 of 8 standards were assessed 1 was met and 1 nearly met. All standards assessed during the previous inspection were met. Sarah Casey the registered manager was present during the inspection. She has many years experience in working with people with a learning disability. Her training achievement includes the Registered Managers Award. She had demonstrated a continuing professional development. It is envisaged that this standard will be met on receipt of verification of compatibility of her current nationally recognised qualifications with the National Minimum Standards. There was evidence from various sources that showed the management approach enabled service users and staff to contribute in the running of the home. Both service users present during the inspection said they had regular meetings and they could contribute to the agenda. They discussed all matters in relation to their life in the home and the environment they lived in. The home had an Investor in People Award. Policies and procedures were accessible to service users in relevant formats. Good practice was noted. Both of the people who lived in the home told Marie that they had house meetings to talk about different things. They were pleased Sarah was their new manager. They could talk to Linda if they wanted.Park LodgePage 8 Requirements from last Inspection visit fully actioned? CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).NA MET (YES/NO)STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for actionRECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * 1 YA37 It is recommended the manager has National Vocational Qualification in Care level 4 or demonstrates current qualifications as equivalent.* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. YA10 refers to Standard 10.Park LodgePage 9 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other enter details here `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total No. of care staff employed (excluding managers) Total No. of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES YES NO YES NO NO NO NO YES NO YES NO YES YES NO NO NO YES NO YES 2 0 0 YES YES YES YES X X 9/02/05 14.00 4Park LodgePage 10 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Adults (18-65) have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No Shortfalls) (Minor Shortfalls) (Major Shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Park LodgePage 11 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · Prospective service users have the information they need to make an informed choice about where to live. Prospective service users individual aspirations and needs are assessed. Prospective service users know that the home they 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.Standard 1 (1.1 ­ 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives and philosophy of the home, its services and facilities and terms and conditions; and provides each service user with a service users guide to the home. The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the service users guide. X X Range of fees charged From To £ £ (per week) YES Any charges for extras If yes, please state what the extras are Hairdressing,transport,papers/magazines, activities. 0 Key findings/Evidence Standard met? This standard was not assessed during this inspection and is referred to in the previous inspection report as standard met. Standard 2 (2.1 ­ 2.8) New service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user, using an appropriate communication method and with an independent advocate as appropriate. 0 Key findings/Evidence Standard met? There had been no admissions since the last inspection. This standard was not assessed during this inspection and is referred to in the previous inspection report as met.Park LodgePage 12 Standard 3 (3.1 - 3.10) The registered person can demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? The process of admission was identified to the Inspector during the last inspection. Before any person was admitted to the home it would be clear if staff expertise and the facilities of the home were sufficient to meet assessed needs. The service user would have to show they were compatible with the existing service users. Staffing arrangements for the home and the presenting needs of the service users would also be considered and the deployment of staff in relation to this. The member of staff present confirmed this. The Inspector discussed training with Sarah Casey the manager. It was evidenced that staff continued in training relevant to their work. Mrs Zephir the owner arranged further training in line with good practice. Advocacy leaflets were given to service users. The home did not admit any person requiring short-term care. Standard 4 (4.1 - 4.5) The registered manager invites prospective service users to visit the home on an introductory basis before making a decision to move there, and unplanned admissions are avoided wherever possible. 0 Key findings/Evidence Standard met? There had been no admissions since the last inspection. Full compliance was noted in previous inspections. This standard was therefore not assessed during this inspection and is referred to in the previous inspection report as met. Standard 5 (5.1 - 5.5) The registered manager develops and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user. 0 Key findings/Evidence Standard met? This standard was not assessed during this inspection and is referred to in the previous inspection report as met.Park LodgePage 13 Individual Needs and ChoicesThe intended outcomes for the following set of standards are: · · · · · 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.Standard 6 (6.1 ­ 6.10) The registered manager develops and agrees with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home, and how these services will meet current and changing needs and aspirations and achieve goals. 4 Key findings/Evidence Standard met? This standard of care planning noted during the last inspection was excellent. During this inspection, the Inspector talked to both service users. Care plans continued to be a valuable resource in meeting needs. The service users had a copy of their care plan for reference. The format used was in keeping with their understanding and was user friendly. The service users and significant others were involved in reviews. Discussion with the service users demonstrated to the Inspector how service users at Park Lodge continued to benefit from autonomy, attainment, citizenship, individuality, diversity, well-being and inclusion. Implementation of care planning showed a continuing personal development for the service user. The home is commended for maintaining the high standard and the credence of effective care planning evidenced during the previous inspection. Standard 7 (7.1 ­ 7.7) Staff respect service users right to make decisions, and that right is limited only through the assessment process, involving the service user, and as recorded in the individual Service User Plan. 3 Key findings/Evidence Standard met? The service users talked to the Inspector about the choices made in respect of autonomy. Service users determined their own life and staff supported them in decisions There was no recall of any restrictions placed on them. The service users both said staff were very supportive and offered advise on any issue that may cause uncertainty. Ultimately their choices and decisions regarding future plans had always been discussed at care planning meetings and this information was recorded. There were no unnecessary restrictions placed on service users living at the home and staff supported them to make informed decisions. A policy was in place that supported the right of service users to make decisions regardless of their disability. There was evidence that service users managed their own finances and the level and type of support needed was documented. The Inspector observed staff during the inspection offering guidance to service users in money management.Park LodgePage 14 Standard 8 (8.1 ­ 8.5) The registered manager ensures that service users are offered opportunities to participate in the day to day running of the home and to contribute to the development and review of policies, procedures and services. 3 Key findings/Evidence Standard met? Service users had been given information about the homes policies, procedures, activities and services. They had their own policy and procedure handbook. It contained relevant information and covered procedures for service users protection and what to do in certain events. All information in the book was appropriate and written in a plain and accessible format. The service users said they had regular house meetings. Sarah Casey the new manager came to these. They could also join in staff meetings where appropriate. This was an opportunity to discuss any issue that had been raised at their house meeting directly with the staff. Service user satisfaction questionnaires continued to be used. Service users could take part in the interviewing of new staff. They had an illustrated aide memoir to ask the candidate questions. Standard 9 (9.1 ­ 9.4) Staff enable service users to take responsible risks, ensuring they have good information on which to base decisions, within the context of the service users individual Plan and of the homes risk assessment and risk management strategies. 0 Key findings/Evidence Standard met? The Inspector did not assess the policy statement on the concept of risk for the home. This was satisfactory during the previous inspection. There was continuing evidence that service users living at Park Lodge benefit from a professional approach by the staff in enabling them to take responsible risk. Standard 10 (10.1 ­ 10.6). Staff respect information given by service users in confidence, and handle information about service users in accordance with the homes written policies and procedures and the Data Protection Act 1998, and in the best interests of the service user. 3 Key findings/Evidence Standard met? There were policies and procedures in place for the staff that included confidentiality and the rights to access files. The service users policy had been given to them in appropriate format. This was kept in their personal files. There were policies and procedures in place for staff viewed during the last inspection that included guidelines for paper and electronic information, telephone, verbal and the rights to access files. All service users confidential records were kept securely locked on the premises.Park LodgePage 15 LifestyleThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 11 (11.1 ­ 11.4) Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 0 Key findings/Evidence Standard met? This standard was not assessed during this inspection and is referred to in the previous inspection report as met. Standard 12 (12.1 ­ 12.6) Staff help service users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities. 3 Key findings/Evidence Standard met? The Inspector talked to both service users. They both continued to live a semi-independent life, within the boundaries of supported living with staff support. They told her about their life at the home and the things they had done since the last inspection. Both service users had personalised activities that included attending college for further education, day centres, and luncheon clubs. One service user had a part time job working voluntarily. Each service user took some responsibility in managing the home. They had had weekly planners that were used to record various activities they did on a daily basis, and included areas where practical daily life skills were encouraged. During the last inspection accomplishment was central in all activities the service users talked about and it was evident this had continued. The Inspector had looked at care plans. They were user friendly and appropriate for each service user. They identified key values of autonomy, attainment, citizenship, individuality, diversity, wellbeing and inclusion. Needs were identified in line with the service users wishes and aspirations. Specialist intervention was identified and recorded with appropriate action taken to support the service users. Service users could follow whatever spiritual preference they chose. Service users knew their key worker and the support they gave. From discussion with the staff member present, there was evidence of ongoing training for staff to support them in their caring role.Park LodgePage 16 Standard 13 (13.1 ­ 13.5) Staff support service users to become part of, and participate in, the local community in accordance with assessed needs and the individual Plans. 3 Key findings/Evidence Standard met? Both service users said they frequently went out. Sometimes they went out together. The home was near to the town centre. The enjoyed shopping and social evenings. Transport was available for service users at all reasonable times. The home had a transport scheme for those who wanted to participate in it. There was evidence of staff work time flexibility that ensured support was maintained at all times including evenings and weekends. Taxis and public transport was also used. Standard 14 (14.1 ­ 14.6) Staff ensure that service users have access to, and choose from a range of, appropriate leisure activities. 3 Key findings/Evidence Standard met? The Inspector talked to the service users about leisure time and how it was spent. Both said they continued to do all the things they liked. This included shopping, visiting friends, evenings out at various clubs, day trips and a variety of other pursuits. One service user said she was going to a concert. Staff support was indicated where needed. They both enjoyed Christmas and were considering a Summer holiday. Standard 15 (15.1 ­ 15.5) Staff support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? There was evidence family and friends of service users could be involved in the activities of daily life in the home. Invitations were sent inviting them to functions arranged for and by service users. Community participation that was identified during the inspection allowed service users to meet people and make friends with people who did not have their disability. There were procedures for staff to follow with information and specialist guidance that was needed to enable service users to make an informed choice in developing and maintaining intimate relationships with people of their choice. This was looked at during the previous inspection. Both service users were in contact with a friend who had moved from Riley Street.Park LodgePage 17 Standard 16 (16.1 ­ 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? There were no changes in house rules for both service users to observe since the last inspection. House rules in relation to smoking alcohol and drugs were outlined in the service user guide, and written in the service users contract. Included was a policy on pets. House rules covered respecting everyones privacy. Both service users had keys to their bedrooms. The locks fitted enabled service users to have privacy, whilst allowing staff access in the event of an emergency. The manager gave both service users present during inspection, privacy as a matter of course. There was no restricted access in the home. Standard 17 (17.1 ­ 17.9) The registered person promotes service users health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 0 Key findings/Evidence Standard met? This standard was not assessed during this inspection and is referred to in the previous inspection report as met. The Inspector did however discuss menu planning, and food shopping with both service users. Good practice was noted.Park LodgePage 18 Personal and Healthcare SupportThe intended outcomes for the following set of standards are: · · · · 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 homes 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.Standard 18 (18.1 ­ 18.11) Staff provide sensitive and flexible personal support and nursing care to maximise service users privacy, dignity, independence and control over their lives. 3 Key findings/Evidence Standard met? The Inspector discussed healthcare with both service users. Key worker support was evident and both service users said they could choose their key worker. They were happy with the current arrangement. During the last inspection cares plans had included individual preferred routines, likes and dislikes and were in formats suitable for service users understanding. Standard 19 (19.1 ­ 19.5) The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. No. of incidents where service users have been taken to Accident & Emergency during last 12 months No. of service users with pressure sores at the time of inspection (from information taken from care notes) 003 Key findings/Evidence Standard met? Both service users said they continued with regular checks for routine health care needs. They were given the support necessary by the staff to manage their own healthcare. They had regular visits to the dentist and could visit their doctor whenever they needed. Medical appointments were recorded and service users said that staff went with them if they needed help. There were policies in for supporting service users in general health management.Park LodgePage 19 Standard 20 (20.1 ­ 20.14) The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the homes policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 0 Key findings/Evidence Standard met? This standard was not assessed during this inspection and is referred to in the previous inspection report as standard met. Standard 21 (21.1 ­ 21.8) The registered manager and staff deal with the ageing, illness and death of a service user with sensitivity and respect. 0 Key findings/Evidence Standard met? This standard was not assessed during this inspection and is referred to in the previous inspection report as standard met.Park LodgePage 20 Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: · · Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm.Standard 22 (22.1 ­ 22.7) The registered person ensures that there is a clear and effective complaints procedure, which includes the stages of, and timescales for, the process and that service users know how and to whom to complain. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days 0 0 0 0 0 0 0 3 Key findings/Evidence Standard met? There was an excellent complaints procedure for service users, which outlined the process of how to make a complaint. It was written in a suitable format for the service users who said they had received a copy. This was discussed with service users during the last inspection. As identified during the last inspection issues, which affected their lives at the home, was discussed at meetings and agreements reached on how to resolve differences.Park LodgePage 21 Standard 23 (23.1 ­ 23. 6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, or inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policy. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists YES03 Key findings/Evidence Standard met? As identified during the last inspection service users had an illustrated guideline on how to identify abuse. There was a policy in the home that covered all types of abuse. Staff had guidelines to follow and the training they had in abuse procedures was based on the `No Secrets In Lancashire publication. Policies and procedures and good practice noted protected service users money and financial affairsPark LodgePage 22 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 24 (24.1 ­ 24.13) The homes premises are suitable for its stated purpose; accessible, safe and well maintained; meet service users individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. 3 Key findings/Evidence Standard met? Park Lodge is a small two bed roomed terrace property located close to Burnley town centre. The home is in keeping with the neighbourhood and is within walking distance to the town. The home was tastefully decorated, furnished and fitted to a very good domestic style standard. The home met the requirements of the local fire, health and safety and building department. Maintenance was ongoing and service users said they were involved in the renewal program of refurbishment.Park LodgePage 23 Standard 25 (25.1 ­ 25. 11) The registered person provides each service user with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyles. Total no. of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1st April 2003) ­ single bedrooms below 10 sq.m usable space or additional compensatory space Total no. of wheelchair users accommodated for in rooms at least 12 sq.m Total no. of wheelchair users accommodated for in rooms less than 12 sq.m Total no. of shared rooms at least 16 sq.m Total no. of shared rooms below 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total no. of single bedrooms Number of single bedrooms with en suite Total no. of double bedrooms Number of double rooms with en suite YES NO NO 2 0 0 0 0 20 0 0 03 Key findings/Evidence Standard met? Park Lodge transferred registration as an existing home to the Commission for Social Care Inspection as an existing home. Accommodation is offered in two single bedrooms. Details of room sizes were set out in the statement of purpose and Service User Guide.Park LodgePage 24 Standard 26 (26.1 ­ 26.4) The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. 3 Key findings/Evidence Standard met? Both service users said they liked their rooms and were satisfied with their accommodation. The bedrooms were furnished to their own needs and choice, which was recorded in the persons individual plan. The doors had appropriate locks and the service users held their own key. Service users had access to a telephone and had a mobile phone. Standard 27 (27.1 ­ 27.6) The registered person provides service users with toilet and bathroom facilities which meet their assessed needs and offer sufficient personal privacy. 3 Key findings/Evidence Standard met? Both service users share a bathroom and toilet.Standard 28 (28.1 ­ 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 3 Key findings/Evidence Standard met? Park Lodge is a small domestic scale terraced house that is part of Park Houses dispersed housing scheme. There is a small yard to the rear of the property. There was a lounge/dining room and a domestic style kitchen that was conducive with the type and style of the home. Laundry facilities were located in the kitchen and are at variance to this standard. It is however an independent resource for both service users in the home. Given the purpose of the home in providing accommodation within domestic style housing in the community, the practicalities of relocating the washing machine would not be an option. Policies that dealt with control of infection had a procedure for this eventuality and were produced for the last inspection. Washing of laundry was scheduled when there was no food being prepared or eaten. Standard 29 ( 29.1 ­ 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the homes stated purpose and the individually assessed needs of all service users. 0 Key findings/Evidence Standard met? This standard was not assessed during this inspection and is referred to in the previous inspection report as met.Park LodgePage 25 Standard 30 (30.1 ­ 30.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 3 Key findings/Evidence Standard met? The laundry facilities in the home were of a domestic scale, and were appropriate to meet the needs of the service users in the home to maintain self-caring skills. The Inspector complemented the high standards of cleanliness continually maintained by both service users. There was protective clothing provided for carers and policies and procedures were in place for the control of infection. Washing machines could be programmed to wash at 65o c if needed.Park LodgePage 26 StaffingThe intended outcomes for the following set of standards are: · · · · · · 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 homes 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.Standard 31 (31.1 ­ 31.7) The registered manager ensures that staff have clearly defined job descriptions and understand their own and others roles and responsibilities. 0 Key findings/Evidence Standard met? This standard was not assessed during this inspection and is referred to in the previous inspection report as met. Standard 32 (32.1 ­ 32.6) Staff have the competencies and qualities required to meet service users needs and achieve Sector Skills Council workforce strategy targets within the required timescales. 0 Key findings/Evidence Standard met? This standard was not assessed during this inspection and is referred to in the previous inspection report as met.Park LodgePage 27 Standard 33 (33.1 ­ 33.11) The home has an effective staff team with sufficient numbers and complementary skills to support service users assessed needs at all times. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. Personal Care No. service users High needs No. service users Medium needs No. service users Low needs Total no. of hours needed No. of staff with NVQ level 2 or above No. of Trainees registered on Sector Skills Council training programme X X X X X No. of full time equivalent Staff with nursing qualification (where applicable) No. staff hours allocated No. staff hours allocated No. staff hours allocated Total Hours Provided X X X X Nursing X X XXX3 Key findings/Evidence Standard met? Records of rotas actually worked showed that the home was staffed to accommodate all the service users needs. This level had been maintained. The deployment of staff had been coordinated to take into account peak time activity and the presenting needs of the service users. Staff turnover was steady with a core of long serving staff. The skill mix of staff had been considered. Senior staff members were indicated on the rota to cover duty at all times with the support workers. Staff meetings were held routinely with records kept.Park LodgePage 28 Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 4 Key findings/Evidence Standard met? The Inspector looked at a number of staff files. They were found to be in good order with relevant documentation in place. References and Criminal Record Bureaux checks had been obtained. Service users had been given an opportunity to be involved in the selection of new staff. To facilitate this service users had an aide memoir in a format suitable for understanding to ask appropriate questions. The Inspector considered this service user involvement to be positive and empowering for them in general. During the last inspection the Inspector looked at policies and procedures for recruitment of staff based on equal opportunities. Service users told the Inspector that they were also involved in staff appraisal. They had their own appraisal form in a relevant format. Park Lodge is commended for the level of support and empowerment given to service users involved in the selection of staff. Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 0 Key findings/Evidence Standard met? This standard was not assessed during this inspection and is referred to in the previous inspection report as standard commended. Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. 0 Key findings/Evidence Standard met? This standard was not assessed during this inspection and is referred to in the previous inspection report as standard commended.Park LodgePage 29 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: · · · · · · · 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 homes policies and procedures. Service users rights and best interests are safeguarded by the homes 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.Standard 37 (37.1 ­ 37.4) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Registered manager qualified to level 4 NVQ in Management and care [by 2005]. NO2 Key findings/Evidence Standard met? Sarah Casey is registered as manager for Park Lodge. She has many years experience working in a residential home for people with a learning disability. She holds relevant qualifications in relation to her work and has demonstrated a continuing professional development. Her accomplishment in training includes the Registered Managers Award and she is currently having other nationally recognised qualifications evaluated in line with National Minimum Standards. It is envisaged that this standard will be met on receipt of verification of compatibility of these in this academic year.Park LodgePage 30 Standard 38 (38.1 ­ 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? Both service users present during the inspection knew about Sarah being appointed manager of the home. They had been informed when the application was sent to the Commission. Park Lodge has continued to ensure service users and staff understand the ethos of the home and of the expectation and responsibility of everyone. There was a complaints procedure for staff and service users. All meetings in the home had an agenda and the service users said they could contribute to this to discuss any issue they felt relevant. Sarah held house meetings with them. Topics that had been discussed were in relation to the managing and running of the home. Both service users told the Inspector they could still approach Mrs Zephir any time with a concern, complaint or issue to discuss. Good practice was noted during the assessment for Investors In People Award the home had received. Standard 39 (39.1 ­ 39.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 0 Key findings/Evidence Standard met? This standard was not assessed during this inspection and is referred to in the previous inspection report as commended. Standards 40 (40.1 ­ 40.6) The homes written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Adults (18-65). 0 Key findings/Evidence Standard met? This standard was not assessed during this inspection and is referred to in the previous inspection report as met. Standard 41 (41.1 ­ 41.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 0 Key findings/Evidence Standard met ? This standard was not assessed during this inspection and is referred to in the previous inspection report as met. Standard 42 (42.1 ­ 42.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 0 Key findings/Evidence Standard met? This standard was not assessed during this inspection and is referred to in the previous inspection report as met.Park LodgePage 31 Standard 43 (43.1 ­ 43.7 ) The overall management of the service (within or external to the home) ensures the effectiveness, financial viability and accountability of the home. 0 Key findings/Evidence Standard met ? This standard was not assessed during this inspection and is referred to in the previous inspection report as met.Park LodgePage 32 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceLead Inspector Second InspectorMarie DickinsonSignature Signature SignatureRegulation Manager Colin Myers Date 23rd March 2005Public reports It should be noted that all CSCI inspection reports are public documents.Park LodgePage 33 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 9th February 2005 and any factual inaccuracies: Please limit your comments to one side of A4 if possible WE ARE WORKING ON THE BEST WAY TO INCLUDE PROVIDER RESPONSES IN THE PUBLISHED REPORT.Action taken by the CSCI in response to provider comments: Park Lodge Page 34 Amendments to the report were necessaryNOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateNONOYESNote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by 5th April 2005, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request.You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planOther: No Statutory Requirements identified at this inspection.Park LodgePage 35 Our Ref: MD/s9533/v211016 D.3 PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies. D.3.1 I Mr Joseph Serge Zephir of Park Lodge Stoney Street confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I Mr Joseph Serge Zephir of Park Lodge Stoney Street am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Park LodgePage 36 Park Lodge / 9th February 2005Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000009533.V211016.R01© This report may only be used in its entirety. 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