CARE HOME ADULTS 18-65
Phoenix Lodge 30 Rougemont Avenue Torquay Devon TQ2 7JP Lead Inspector
Michelle Finniear Unannounced Inspection 18th October 2007 11.15 Phoenix Lodge DS0000018418.V349392.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 Phoenix Lodge DS0000018418.V349392.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. Phoenix Lodge DS0000018418.V349392.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Phoenix Lodge Address 30 Rougemont Avenue Torquay Devon TQ2 7JP 01803 615538 01803 615538 phoenix.lodge@craegmoor.co.uk Craegmore.co.uk Parkcare Homes Ltd 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) Mrs Evelyn Joyce Ralph-Brown Care Home 4 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (4), Physical disability (4) of places Phoenix Lodge DS0000018418.V349392.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The registered person may provide the following category of service only: Care home providing personal care- Code PC to service users of either gender whose primary care needs on admission to the home are within the following categories: Physical disability- Code PD 2. Mental disorder, excluding learning disability or dementia- Code MD The maximum number of service users who can be accommodated is 4. Date of last inspection 22nd May 2007 Brief Description of the Service: Phoenix Lodge (previously Rosehill House) cares for 4 people with physical disabilities and/or mental disorder. It specialises in caring for people who have suffered a brain injury and is owned by a subsidiary of Craegmoor Healthcare Limited. The home aims to be a short term facility enabling people to live in a small domestic environment prior to living more independently in the community. The house is in a residential area of Torquay and near to community amenities. Phoenix lodge is wheelchair accessible with level access throughout and adapted shower rooms and a bathroom with an electric in bath hoist. There are four single bedrooms, an office/staff room, lounge, dining room, kitchen and laundry room. The garden to the back of the house is ramped with a patio area and seating. Fees range from £1275 per week upwards, dependant on need. Copies of the most recent inspection report are available at the home. Phoenix Lodge DS0000018418.V349392.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This report is a summary of a cycle of Inspection activity at Phoenix Lodge since the last inspection visit in January 2007. The home changes it’s name in September from Rosehill House, to emphasise the separateness from Rosehill rehabilitation unit, owned by the same company and also in Torquay. To help CSCI make decisions about what it is like to live at Phoenix lodge the manager gave us information in writing about how the home is run; documents sent to us since the last inspection were looked at, along with what we found when we last visited; and a site visit of 6 hours was carried out without saying when we were coming. We talked to the manager and staff on duty during this visit and we looked at some of the records the manager keeps, such as medication records; we looked at the house to see if it was clean and in a good condition. We also looked at the records about the people who live at the home and their experience of care was ‘tracked’ looking at how well the home understands and meets their needs, and the opportunities and lifestyle they experience. Time was spent with some of the people who lived at the home, and some completed questionnaires about what it is like to live at Phoenix Lodge. We also sent questionnaires to doctors and nurses who visit the home. This is so that we could get as many peoples views as possible about how the home is run. What the service does well:
Phoenix Lodge provides a homely place for people who need to live there for a short time, learning how to live again in a small home, and then helps them to live more independently elsewhere. The staff team seen were committed to the people living at the home, and were clear about their needs including the need for private and rest time. The building is accessible, and on a single level, so that people with wheelchairs can get about independently. Staff could be seen working with people to help them develop new links in the community to provide social networks for when they leave the home. On this visit for one person this included a trip to a local animal charity to do voluntary work. It also included finding out information for this person from their past. Phoenix Lodge DS0000018418.V349392.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection?
Each person living at the home now has a thorough assessment prior to admission to ensure Phoenix Lodge can meet his or her needs before they make a decision to live there. An application was made to register the manager, and this has now been completed. This is so that there is someone legally recognised to be in day to day charge of the home. A service user guide has been provided to ensure all people living at the home or thinking about living at the home can have information about Phoenix lodge in a format they can understand. Any restraint or restrictions on people living at the home are part of a formal written plan, including all actions to be taken to decrease any behaviours before any intervention is carried out. These should be agreed by a multi disciplinary team, involving the person themselves wherever possible, and involve information on any risks involved. No physical restraint is being used on a service user unless full records are kept of any restraint, including what was done and by who. This is to make sure that peoples right’s are protected and that any action taken to prevent the person hurting themselves or someone else is the least that will stop the behaviour. A full quality assurance system is being implemented to look at and improve the quality of care at the home for the people who live there. The Home’s Statement of Purpose has been updated to show the changes to the type of care the home is going to offer. Care plans clearly state what support is needed and how it is to be given. Plans have been drawn up with the person concerned, and are goal focussed with timescales set at regular reviews. This is to ensure that care is delivered in the same way by all staff and is given in the way the person wishes. Goals help people focus on improvements, with something to aim towards. Phoenix lodge has an equality and diversity policy. This is to reduce any risks of discrimination. One person is now managing their own finances. This helps to make sure people are as independent and have as much control over their lives as possible. The complaints procedure has been made accessible to people living at the home, so that everyone can understand how and to who complaints should be made. Staff are not handling medication before it is given to the person for whom it is prescribed. This is to avoid medication becoming contaminated.
Phoenix Lodge DS0000018418.V349392.R01.S.doc Version 5.2 Page 7 Medication administration sheets are being completed when the person has taken the medication to avoid the risks of medication not being taken being wrongly recorded. Every effort is being made to ensure that services provided meet all the cultural needs of the people accommodated, including familiar foods. This is so that people can lead their lives in ways that are familiar to them. Repairs have been undertaken to the damaged area of the bath surround and broken tiling in the bathroom. This is so that people living at the home can live in pleasant and hygienic surroundings. Cleaning materials are generally being stored safely, and data sheets are available in case of accidental misuse. This is so that people know what to do in use of accidental misuse. 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
Phoenix Lodge DS0000018418.V349392.R01.S.doc Version 5.2 Page 8 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Phoenix Lodge DS0000018418.V349392.R01.S.doc Version 5.2 Page 9 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 Phoenix Lodge DS0000018418.V349392.R01.S.doc Version 5.2 Page 10 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, 3, 4, 5. Quality in this outcome area is good. People thinking about moving into phoenix lodge receive a full assessment and information about the home to enable them to judge whether it is the right place for them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection the manager has amended the statement of purpose and service user guide. These documents provide information about what the home offers and aims to achieve with people who live there, as well as the services and facilities available and are on display in the homes dining room area. Much of this information has been made available in formats to suit the needs of people considering moving into the home. A new brochure has also been provided During the inspection site visit the records of a recent admission were examined and discussion was held with the manager concerning how the process had been followed through. Although this individual had been referred from another home within the group, a full discharge and admissions process had been followed through. This demonstrates that Phoenix Lodge is working as an independent unit. Phoenix Lodge DS0000018418.V349392.R01.S.doc Version 5.2 Page 11 The manager had visited the person wishing to move to Phoenix Lodge and had held discussions with staff at the previous placement, reviewed records and outlined to the social worker what the unit had to offer. The person had then visited Phoenix Lodge himself on two occasions and had an opportunity to judge whether they felt it was appropriate for them. Full assessments were completed by the manager in relation to this persons needs so that she was clear the home could meet their needs and provide a positive service. The person spoken to confirmed that having a stay at Phoenix lodge had helped them feel more confident in moving on and had supported them in helping to find a flat. Phoenix Lodge aims to provide a short term and intensive programme of rehabilitation in a domestic style setting. Statements of terms and conditions are available, but may not be available in a suitable format for all people living at the home to understand. Phoenix Lodge DS0000018418.V349392.R01.S.doc Version 5.2 Page 12 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, 8, 9 Quality in this outcome area is good. Each person at the home has a plan of care, with which they have participated and which ensures their needs are met. People are consulted on lifestyle choices and routines within the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Plans of care for two people were seen during the course of the inspection site visit. These plans, constructed in different formats to meet the needs of each individual, were person centred and had been regularly updated. Person centred means they were written in a way that ensured the individual persons needs remained the focus of the plan of care. As an example, one plan seen contained pictures and symbols which were appropriate to that persons needs, the other plan was more text-based. Plans were comprehensive, and had been drawn up with the support of the person himself wherever possible. This helps to ensure that plans reflect care delivery in the way that the person wishes it to be delivered. The plans seen
Phoenix Lodge DS0000018418.V349392.R01.S.doc Version 5.2 Page 13 also contained evidence of consultation and assessment from a variety of other professionals, such as occupational therapists, physiotherapists and speech and language assessments. Plans were being regularly reviewed, and observation during the inspection demonstrated they were an accurate reflection of the care actually being delivered. This was also discussed with one person moving out the home who confirmed plans in the file were being acted upon by staff. Goals are provided for each person including activities and Independence tasks. For one person working towards independent living this involved them cooking, shopping, cleaning their own rooms and taking responsibility for social contacts and activities. This person commented that staff were working “above and beyond what they were required to do” to ensure opportunities were available. People living at the home have opportunities every day to affect the way the home operates. Staffing levels are flexible and based upon the needs of individual on a daily basis, and formal meetings such as the your voice meeting allow people to raise any concerns or issues or challenge any practice that they are unhappy with. Minutes of the most recent your voice meeting were seen, and discussion was held with the manager on actions that have been taken following this meeting to ensure service users comments were reflected in changes in the home. People eat together during the day and this also gives opportunity to discuss and review/change plans. The files seen contained information on risks and risk-taking. For some people living at the home risk-taking is an important part of developing their skills and life opportunities. Assessments of risk and management strategies to reduce this wherever possible are included in files, and this sometimes includes information from supporting agencies, for example mental health teams. Phoenix Lodge DS0000018418.V349392.R01.S.doc Version 5.2 Page 14 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, 14, 15, 16, 17 Quality in this outcome area is adequate. People at Phoenix lodge are encouraged to develop new skills and social networks in preparation for a move into more independent living. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People living at Phoenix Lodge have opportunities for personal development, to take part in the life of the local community, and develop personal relationships. During the course of the inspection site visit people left the home to go to craft groups, when shopping, went out to try a new wheelchair and were taken to a local animal rescue centre to do voluntary work walking dogs. Each of these activities were supported by a member of staff. Records of activities and opportunities available to people are recorded on the files, and on the daily shift plan sheets which were also seen. These
Phoenix Lodge DS0000018418.V349392.R01.S.doc Version 5.2 Page 15 demonstrated that a variety of opportunities are available, including people being able to invite friends back to Phoenix Lodge. One person living in the home had recently planned to cook a special meal for a friend at the home and use is made of other social networks, mental health groups, evening classes as well as peoples family or existing friends. The home has a vehicle that people can use for transport within the community, however this is not accessible to wheelchair users. For wheelchair users a wheelchair accessible taxi is provided, which is paid for by the home for appointments and by the person living at home for social events. People living at the home are involved in shopping twice a week, and plan menus. A board in the home demonstrate which staff are coming on duty, and wherever possible particular staff are selected to work with service users with whom they have something in common. Evidence was seen of craft work having been completed by one person living at home, which was valued and on display. People are encouraged to use community facilities and services, including pubs, clubs and restaurants. It is understood that alterations are to take place to the homes kitchen to make it wheelchair accessible, as currently access is limited. The minutes of the Your voice meeting held recently showed that one person living in the home was unhappy with the meals served and wanted more vegetarian choice. Menus are decided weekly by people living at the home and one person as part of a Independence program cooks and shops for their own meals. Peoples rights are respected, including the right to follow their chosen lifestyle and not participate in opportunities available. Phoenix Lodge DS0000018418.V349392.R01.S.doc Version 5.2 Page 16 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, 20. Quality in this outcome area is good. People living at the home have their healthcare needs met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the site visit two peoples files were examined, discussions were held with the manager and a person living at the home about their healthcare needs and equipment and records were examined. These showed that peoples needs were being met. The care plans seen showed that people had been consulted in the development of the plans and that their agreement had been sought on the way they wished their care to be delivered. Discussion was held on equipment available in the home, which has been supplemented since last inspection by the new mobile hoist. The home has other equipment to meet each individuals need following occupational therapy/physiotherapy assessment, and support from community professional services such as speech and language therapists. Occupational therapy and physiotherapy support at present is being supplied by another home within the
Phoenix Lodge DS0000018418.V349392.R01.S.doc Version 5.2 Page 17 group, however it is understood that in the future the home will have access to their own occupational therapist. District nurses visit to carry out nursing tasks, for example dressings, and community psychiatric nurses visit to support individual service users as necessary and support the home with any specialist needs. The medication systems at the home were seen, and found to be satisfactory. Staff complete competency assessments before they administer any medication, which is supplied in a monitored dosage system. This means that be pharmacist supplies medication in a series of colour-coded blister packs. This helps to reduce any errors and make it easy for staff to ensure that medication has been given. All medication administered is signed for individually on medication administration records, also the recording drugs bought into the home and any receipts for medication no longer needed and returned to the pharmacy. The home does not currently hold any controlled medication, however a controlled drugs book has been provided since last inspection. Phoenix Lodge DS0000018418.V349392.R01.S.doc Version 5.2 Page 18 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, 23. Quality in this outcome area is good Good policies are in place to protect people living at the home from abuse and to address any concerns or complaints that may be raised. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Phoenix lodge has a complaints procedure on display in the homes dining room, and this is now also available in a more accessible format for some of the people currently living at the home. People living at the home who completed questionnaires indicated that they were clear about who they would talk to if they were unhappy about something, and that they felt safe at the home. This was confirmed in a discussion with one person living at the home. Other people with communication difficulties would find this more challenging and staff might have to rely on interpretation of behaviour or gesture to determine that someone was not happy about something at the home. The home has on display a whistle-blowing policy for any staff concerned about anything they see at the home or during the course of their work. This helps to increase protection for people living at the home by ensuring that staff have information about what to do if they suspect abusive practices. Following the last inspection a complaint was received from a family member about the home. This related to some long standing issues and concerns raised
Phoenix Lodge DS0000018418.V349392.R01.S.doc Version 5.2 Page 19 under previous management. These were investigated by the homes management and have now been resolved. No other complaints have been received. The home has started a complaints and comments box for people to make suggestions about improving services. Staff receive training in adult protection and the home has a policy and procedure which complied with local guidance and protocols. Two member of staff who completed questionnaires stated they knew the action they would take if an allegation had been made. This showed a good understanding of the system and should therefore help protect people living at Phoenix Lodge from abusive practices. Phoenix Lodge DS0000018418.V349392.R01.S.doc Version 5.2 Page 20 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, 25, 26, 27, 28, 29, 30. Quality in this outcome area is adequate Phoenix lodge provides a comfortable and accessible near domestic environment. The kitchen is poor. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Phoenix Lodge is set within a residential area of Torquay, close to the hospital and access roads into the main town area. During the site visit, a tour was made of all areas of the home, which is on a single level, with parking and an enclosed garden. Each person living at the home has a single bedroom, all of which are individually furnished and decorated to suit each persons interests and needs. Where aids and adaptations for a specific disability have been required efforts have been made to ensure rooms keep a homely feel. Phoenix Lodge DS0000018418.V349392.R01.S.doc Version 5.2 Page 21 There is one bath with an in bath electric hoist and a level access shower, so that people living there can have some choice of where they bathe. There is a mobile hoist available. The home has risk assessed hot surfaces and provided water temperature regulation to baths and showers. This means people living at the home are protected from scalding, as water temperatures are automatically controlled to ensure they do not exceed 43 degrees centigrade. A basin tested at random was within this limit. Communal areas are bright and comfortably furnished and all areas seen were warm and odour free. There are appropriate arrangements for the storage and disposal of clinical waste, which support people’s privacy and maintain control of any odour or infection risks. The home has a rear garden and patio area, which is accessible to people who use a wheelchair. This is an area where people living at the home can smoke and there is seating and some protection from the weather. The manager has plans to improve this area to provide a sensory area and perhaps space for growing vegetables. There is a laundry to the rear of the home, which has machines capable of achieving a good standard of infection control. However the refrigerator for food storage is also situated in this area. The homes kitchen is in a poor condition with door fronts being damaged and not easily cleanable, although the flooring has been replaced. Phoenix Lodge DS0000018418.V349392.R01.S.doc Version 5.2 Page 22 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, 36. Quality in this outcome area is good. The staffing arrangements mean that staff are able to support people living at the home appropriately. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the inspection site visit three staff files were selected to reflect the staff on duty on the day of the visit; Discussion was also held with management and a person living at the home about the staffing arrangements; and a staff member discussed their role and training they have undertaken. On the day of this visit there were three care staff and the manager on duty for four people at the home. This meant that everyone had an opportunity to have some 1:1 time with staff either in the home or out on activities. Staff at the home are involved in cooking and cleaning, gardening and shopping as well as care tasks. The staff files seen were divided into two files for each individual, one containing personnel information on their recruitment and employment and the
Phoenix Lodge DS0000018418.V349392.R01.S.doc Version 5.2 Page 23 other information and certificates on training and appraisals they have received. The files confirmed that a full recruitment process is followed through when people are appointed to work at the home. This includes taking up of references and criminal records bureau checks. These help, in conjunction with risk assessments, to ensure that people are cared for by people who are suitable to be working with vulnerable adults. Staff who completed questionnaires indicated that the recruitment process had been followed when they were appointed. Staff when first appointed are on a probationary period, and there are job descriptions for each staff role. Training records include information on Induction training undertaken. This was not dated but had been signed by the staff member concerned to show they had understood what they had been shown or taught. Some older induction processes had not been recorded so files for staff who had been there longer were not fully complete. Training plans and a matrix are in place to show the training staff have received and also what is planned. The manager confirmed that the home are working on improving the number of staff at the home who have National Vocational Qualifications. These are a work based assessment reflecting the competency of the person in their job role. Some core training needs to be reviewed and updated. The manager has commenced a programme of supervision for staff. Supervision is a system that combines staff personal development and performance assessment and is aimed at helping staff to work to their full potential in supporting people living at the home. Each person has received this at least once and it is aimed this will be delivered six time a year for each person. Phoenix Lodge DS0000018418.V349392.R01.S.doc Version 5.2 Page 24 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. Quality in this outcome area is good. The home is being well managed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager of the home is very experienced and has achieved her registered Managers Award, which is a specialist qualification for managing a care home, as well a being a registered nurse. Since being at the home in May 2007 she has been registered and has worked hard to develop systems and consistency for the home and provide strong leadership. One person living at the home said “You couldn’t find a better person to be in charge”. A Quality assurance system is being implemented which will ensure that people living at the home can affect the way the home is run, and ensure that good practice is maintained. This includes a series of internal and external audits
Phoenix Lodge DS0000018418.V349392.R01.S.doc Version 5.2 Page 25 carried out to make sure that for example maintenance issues are being addressed. The home also has meetings, called ”Your voice”, where people, living at the home are encouraged to have their say about the way the home is being run in a supportive atmosphere. Comments are then used to make changes. The home also has a series of questionnaires which have been sent out to relatives and visiting professionals about the operation of he home. These help gather as many views as possible about the running of the home and improve services for the people living there. From these an annual development plan is formulated to look at what is working well and what could be changed. Discussion was held with the manager about Health and safety arrangements at the home and a number of documents and certificates were seen, such as testing of water quality and servicing arrangements for hoists and other moving equipment. The home does not currently have a first aid risk assessment but staff have had training in first aid. The home has not received an assessment from the Environmental Health officer for several years. Regular Fire alarm tests and fires drills are undertaken and there are policies and training for Infection control, moving and handling, security of the premises and electrical safety. Phoenix Lodge DS0000018418.V349392.R01.S.doc Version 5.2 Page 26 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 3 2 3 3 3 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 3 x Phoenix Lodge DS0000018418.V349392.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3 Refer to Standard YA5 YA13 YA30 Good Practice Recommendations Accessible Statements of terms and conditions of residency should be made available to people living at the home. The provision of an accessible vehicle to meet the needs of all the client group accommodated should be considered. Consideration should be given to replacing the kitchen and re-siting the refrigerator out of an area where laundry is washed. The home should provide a first aid risk assessment Supervision should be carried out six times a year for all staff. 4. 5. YA42 YA36 Phoenix Lodge DS0000018418.V349392.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Phoenix Lodge DS0000018418.V349392.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
