Inspection on 24/10/07 for Russell Lodge

This inspection was carried out on 24th October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Russell Lodge 30/11/06

Russell Lodge 12/10/05

Russell Lodge 21/07/05

Russell Lodge 16/12/04

Russell Lodge 06/05/04

Russell Lodge 30/03/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Russell Lodge 18 Russell Gardens, Ley Street Ilford Essex IG2 7BY Lead Inspector Stanley Phipps Unannounced Inspection 24th October 2007 11:40 Russell Lodge DS0000025924.V354085.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 Russell Lodge DS0000025924.V354085.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. Russell Lodge DS0000025924.V354085.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Russell Lodge Address 18 Russell Gardens, Ley Street Ilford Essex IG2 7BY 020 8554 4858 020 8518 4545 ragini@careone.co.uk 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) Care One Ltd Mrs Ragini Sivakumar Care Home 5 Category(ies) of Learning disability (4), Learning disability over registration, with number 65 years of age (1) of places Russell Lodge DS0000025924.V354085.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. People with mild to moderate learning disabilities and associated mild to moderate physical disabilities. One named person beyond the age of 65 to be accommodated. Date of last inspection 30th November 2006 Brief Description of the Service: Russell Lodge is a registered care home providing accommodation and support for five (5) residents with a moderate learning disability. The home aims to support residents in order for them to access and participate in mainstream as well as specialist resources in the community in which they live, within their individual capabilities. Russell Lodge is a semi-detached property situated in the Ilford area of the London Borough of Redbridge. The area is well served by public transport and there are many easily accessible facilities within the local area. There are three single rooms on the first floor and two on the ground floor, one with en-suite facility. Residents also have access to a communal lounge, dining area, kitchen, a laundry facility and a rear garden. A Service User Guide is available at the time of assessment. The current fees are £800.00 to £1150.00 per week, depending on service users’ needs. Additional charges are made for personal items such as hairdressing and toiletries and service users also pay for all outside leisure activities such as bowling, cinema etc. Russell Lodge DS0000025924.V354085.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out on the 24/10/07. It was unannounced and a key inspection of the service, which meant that all the key minimum standards for ‘Younger Adults’ were assessed. The assessment considered information provided in the Annual Quality Assurance Assessment (AQAA) by the registered persons as well as feedback from external professionals. An assessment of policies and procedures, medication practice, activities, menus, all records required by regulation, service user plans and the environment was undertaken. Over the course of the inspection discussions were held with several staff, two service users and the manager. Formal interviews were held with one member of staff and two service users. The inspection also considered comment cards completed by staff and service users. The inspection found that service users were generally pleased with the service provided at Russell Lodge. The registered persons did act upon most of the previously made requirements, which would have had a positive impact on the outcomes for service users. However, there are some areas that require further improvement, which are identified in this report. It should be noted that the verbal feedback from relatives and external professionals has been positive regarding the services provided at Russell Lodge. What the service does well: What has improved since the last inspection? An updated assessment and care planning system is now in place, the latter of which is more person centred. Service user plans now provide evidence of how they make decisions that affect their lives. Russell Lodge DS0000025924.V354085.R01.S.doc Version 5.2 Page 6 Risk assessments were generally updated and this included a community risk assessment. Service users have been using the community in line with their needs and preferences. Their personal care preferences were recorded more appropriately in their individual plans. Safety records bore evidence of regular fire checks with a fire risk assessment in place to ensure that the home is a safer place. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Russell Lodge DS0000025924.V354085.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Russell Lodge DS0000025924.V354085.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (1,2) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Service users have updated information, which they could rely on in making a decision to live at Russell Lodge. Their needs are assessed in detail prior to admission to determine the suitability of the home in meeting them. EVIDENCE: An updated statement of purpose and service user guide detailing the philosophy, aims and overall services provided was in place at Russell Lodge. Both documents were available to service users and consideration has been to meeting the diverse communication needs of the service user group. As a consequence, the service user guide is available in audio and in one Asian language. Plans are in place to develop the documents in easy read pictorial formats. In general they comply with the National Minimum Standards and the Care Homes Regulations 2001. There were no admissions to the home since the last inspection and as such the home continues to maintain one vacancy. The pre-admission documents were found in order at the previous inspection, and service user plans have been developed from those assessments, which were carried out by the management of the home. The home’s current admissions’ process ensure that service users participate in choosing whether to live at Russell Lodge, part of which involves them having a trial stay at the home. Service users have some assurances that their needs would be met, once they decide to live there. Russell Lodge DS0000025924.V354085.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (6,7,8,9) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Good systems are in place to ensure that the changing needs of service users are reflected in their individual plans. Service users are consulted more and are involved in decisions affecting their lives. They are supported to maintain their independence and safety, within a risk management framework. EVIDENCE: Service user planning was in place for each individual living in the home and from discussions with them, they were quite happy to be part of the process. This document is generally used as a working tool by staff in the home and each service user is assisted by their key-worker in developing this document, which sets out their aims and aspirations. One individual stated; ”my key worker helps me with planning what I want to do”. Another said; “my key worker helps me get out and about in the community, which I enjoy”. The plans viewed were reviewed regularly, updated and reflected the needs of service users. An important improvement that was noted included the service users being able to contribute to the decision-making process in their lives. This was extended to buying their clothes, choosing activities and their right to Russell Lodge DS0000025924.V354085.R01.S.doc Version 5.2 Page 10 refuse, which is positive. Most service users engage with the opportunities provided and so retain control of their lives. It must be noted that the levels of support that was given varied from individual to individual, which meant that service user engagement was specific and purposeful. The registered manager recently undertook training in person centred planning and plans are in place to cascade this down to the staff team. There was evidence that service users were consulted on what they would like to do. This was determined mainly through individual meetings, reviews, service user meetings and annual surveys that are carried out. Two of the service users spoken to confirmed that they are involved in decisions made in the home for example, going on a five-day vacation to Holland this year and staying in a hotel. In speaking with relatives they expressed high levels of satisfaction with the level of service user involvement in the home. The registered persons are working towards making information more easily accessible to service users including the access to advocacy services. Service users contribute towards various aspects of the home’s maintenance including drying crockery and cutlery, dusting and cleaning, helping with cooking and doing the food shopping, which is positive. Risk assessments were in place for each service user, which were linked to their individual plans. They were updated and reviewed annually or as and when the need arose. One of the service users interviewed showed an awareness of why a risk plan was in place for him. More importantly, he was party to its development and so, felt in control while being safer. On examining the risk assessments, clear actions were recorded to keep the risks to a minimum and this forms an important part of safeguarding adults. The risk management plan was aimed at promoting service users’ independence and as such was developed in the least restrictive way. It was noted that community outings were risk assessed to ensure participants’ safety. This is positive. Russell Lodge DS0000025924.V354085.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (12,13,15,16,17) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Service users are enabled to participate in their community, enjoy a range of activities and are able to maintain and develop social and personal networks of their choosing. They are supported to exercise their rights, which are respected and promoted by staff in the home. Service users also enjoy a variety of meals that meet their cultural and nutritional needs. EVIDENCE: There was evidence that each service user is supported to participate in activities that were best suited to them. During an interview with one individual, he outlined what he currently did, which included going bowling, attending an evening club and going out for walks. He was also clear that he is generally able to do what he wants to and this suited him. Another individual spoke about going for train rides, bowling and visiting Macdonalds. While none of the service users were in pursuit of adult education, the management and staff expressed a commitment to following this up, once service users expressed an interest in this area. One service user visits a day centre up to four times per week. It is envisaged that, as person centred planning becomes more established in the home, opportunities for more individualised exploits Russell Lodge DS0000025924.V354085.R01.S.doc Version 5.2 Page 12 would increase. It must be said that service users and their relatives were extremely pleased with the level and quality of personal activities provided by the home. From talking to relatives, service users, and external professionals, it was clear that life at Russell Lodge involves using the community resources and facilities. Service users access the local entertainment centres, restaurants, shops, parks, picnics, the library and their local GP. Staff work flexibly to enable this, despite the difficulties experienced in the availability of community resources for service users with specialist needs. Service users informed that they enjoy going out and were happy with the support given by staff in enabling this. It also became clear that service users were using various forms of public transport to go about their daily lives, which is positive. On the day of the inspection two service users were observed going out bowling and they were able to do so for as long as they wished. Both reported that they had a great time, which is positive. From discussions with service users and their relatives and from assessing their individual plans and care records, it was noted that service users are encouraged to maintain their friends and families network. Relatives were invited to functions and reviews held for service users, and most reported that they are kept well-informed of the progress and developments affecting their loved ones. Service users in some cases go out to visit their relations and it was clear that every opportunity is given to ensure that service users are able to maintain their personal and social networks, which is positive. One hundred per cent of the feedback received from service users indicated that they felt respected by the management and staff at the home. A similar sentiment was echoed in the feedback obtained from external professionals. Throughout the course of the inspection, the rights of service users were respected as evidenced through the interventions undertaken by staff with them. Service users now have information regarding access to advocacy services. They also have regular meetings where they are able discuss a range of topics that affected them. This included; outings, menus, internal activities and things that affect them in the home. Some of the internal activities noted involved colouring and painting, and literacy and numeracy. Service users have the benefit of a key for access to their bedrooms. Their responsibilities for housekeeping are documented in their service user plans through their choice, and they were positive about it. Service users were engaged with staff as a matter of choice, throughout the inspection, notwithstanding the fact that individuals wanting to spend time alone were encouraged to so do. Clear guidance is in place for handling service users’ mail and staff were observed addressing service users by their preferred names. There was a high level of satisfaction with the meals provided at Russell Lodge. This resulted from the level of service user involvement in this process, which Russell Lodge DS0000025924.V354085.R01.S.doc Version 5.2 Page 13 included planning menus to helping out where possible with the meals. It was clear that there were varying levels of skills in this area, but opportunities for involvement were available to all. Lunch was observed and this was a very personal and relaxed activity. Staff more times than often have a meal with the service users and engage with them for a more pleasurable experience. During the course of the visit the dessert was placed on the table before a service user had completed her meal and this issue was picked up and dealt with by the registered manager. Meals were varied, diverse, and reflective of the nutritional needs of individuals. Menus are decided weekly, which then influences the food shopping. However, they should be developed in user-friendly formats. There was a good supply of food and drink available to service users, which could be accessed as when they needed it. Service users had access to healthy snack options, which were noticeable over the course of the inspection. Meals also took into consideration the health requirements of individuals and a system of monitoring service users’ weight was in place to in relation to the meals arrangements at Russell Lodge. One relative complimented the input of staff stating; “my relative now has a better appetite and has even lost some weight - looking much healthier now”. This is positive. Russell Lodge DS0000025924.V354085.R01.S.doc Version 5.2 Page 14 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) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Service users enjoy personal support in a manner that is best suited to them. Good arrangements are in place to provide for their physical and emotional health needs, although more attention must be centred on meeting some aspects of the individual’s emotional needs. Health promotion is generally enhanced by the staffing input and support with medication. EVIDENCE: Feedback received from service users indicated that their privacy was promoted, where they were supported with personal care. The staffing arrangements are adequate to offer same-gender care, should this be required and a gender policy is in place to facilitate this. Approximately ninety seven per cent of the service user feedback received informed that they could do what they want, including going to bed, waking up, and doing what they want at anytime during the day. Guidance and support is offered at various levels and individually to service users e.g. supporting an individual to attend the day centre or a GP appointment. This is usually done in accordance with their service user plans. Service users have their individual style of dress and this was specific to their age, culture, choice and design preferences. Three of the service users spoken Russell Lodge DS0000025924.V354085.R01.S.doc Version 5.2 Page 15 to knew their key workers and specialist input is accessed to obtain support in relation to their disabilities, which is positive. All service users are registered with a GP and records assessed indicated that arrangements are in place for them to see other health professionals such as the dentist, community nurses, chiropodist and the opticians. An example of good practice is where a visiting dentist attends the home to look at the dental needs of service users. Sound records were maintained where service users attended health related and professional appointments e.g. GP or a psychiatrist. Adequate arrangements are in place for service users to see professionals privately. It was noted that service user plans contained details of the emotional healthcare needs of service users. The management should keep under review, the systems put in place to support service users emotionally. The registered persons demonstrated the capacity to make interventions to ensure that the healthcare needs of service users are provided for. Monitoring records were in place and updated, and this included monthly weight charts for service users. Service users were given support with their medication and there was good evidence to confirm that all staff involved with this had training in this area. One hundred percent of the feedback received from service users and external professionals indicated that they were happy with the quality and level of support they received with their medication. The medication records were thoroughly assessed and they were well maintained. Instructions were clearly laid out for staff to follow, which minimised the risk of errors being made. Two–monthly audits are carried out by a chemist from the Britannia, which adds to the quality monitoring of drugs used in the home. Russell Lodge DS0000025924.V354085.R01.S.doc Version 5.2 Page 16 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) People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Service users and their relatives are assured that when complaints are raised they would be acted upon. Adequate arrangements are in place to protect from abuse. However, improvement is required in this area to enhance the protection that is currently available to service users. EVIDENCE: Service users spoken to indicated that they could raise concerns in their service user meetings, with the manager, their key-worker or social worker. A copy of the complaints procedure is available to all service users, although consideration must be given to the effectiveness of the format currently used, as it should be in line with the diverse communication needs of the service user group. This was discussed with the registered persons at the time of the inspection. The complaints record was examined and in most cases, a complete audit trail was established for each complaint raised. Staff interviewed showed a good understanding of the need to support service users to complain. This is positive. There were good systems in place to safeguard service users from abuse, which included a clear and accessible protocol on abuse and specific training in relation to safeguarding service users. From observing practice in the home, speaking with the management and staff team – it was clear that from a practical point of view, steps needed to be taken to further prevent service users from the risk of abuse. One of the key issues was in the handling of service users’ finances in which there was an absence of service user signatures, when they either agree the use of money or directly use funds from their account, which is held by the registered manager. This practice did not assure accountability and transparency. Russell Lodge DS0000025924.V354085.R01.S.doc Version 5.2 Page 17 An assessment of a random number of service users’ finances did not establish a clear audit trail of how and when funds are moved around in some accounts. This was clarified through explanations from the registered manager, which is not in line with best practice. The use of the registered persons personal cards must not be linked with the personal finances of service users. The previous requirement is therefore repeated. Another key area of concern was the lack of action that was taken following an incident that occurred just prior to the inspection. An intervention was made by the staff in the form of restraint to promote the safety of a service user and a staff member that was supporting her. Following the restraint, appropriate observations were not made and/or recorded on the service user in relation to her physical being. It turned out that there was some reddening of the skin, possibly resulting from the staffing intervention – but this was missed because no checks were made. As a consequence, a referral was not made to the safeguarding adults coordinator. This was discussed in detail with the registered persons and a referral was subsequently made. There is a need to improve the practices with regard to safeguarding adults at Russell Lodge. Russell Lodge DS0000025924.V354085.R01.S.doc Version 5.2 Page 18 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): (24,30) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Service users live in a safe, comfortable environment with adequate and well-maintained facilities. A high standard of cleanliness ensures that the home remains a safe place for all. EVIDENCE: On the day of the inspection the home was clean, tidy and in good decorative order. Service users benefit from a range of facilities including: toilets, bathrooms, bedrooms, lounges for dining, relaxation and recreating, and a rear garden. The environment is homely and service users were observed enjoying various parts of it during the course of the inspection. Feedback from external professionals indicated that the home is always well maintained. The fittings and furnishings were in good order and a programme of maintenance and renewal is in place. One hundred per cent of the feedback received from service users and their relatives indicated that they were happy with the standard and quality of the accommodation provided at Russell Lodge. There was an improvement in this standard in that there were regular checks and maintenance on the fire systems in the home. More importantly, a fire risk assessment was carried out on the home to ensure the safety of service users, Russell Lodge DS0000025924.V354085.R01.S.doc Version 5.2 Page 19 staff and visitors to the home. A laundry facility is in place, which is used by staff in supporting service users to launder their washing. An infection control policy is in place and service users and staff are encouraged to work in line with this e.g. hand-washing. The laundry equipment is designed to cater for soiled linen and appropriate arrangements were in place for maintaining them. The home was free of offensive odours and the registered manager confirmed that it complies with the Water Supply Regulations 1999. Russell Lodge DS0000025924.V354085.R01.S.doc Version 5.2 Page 20 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) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Service users benefit from a staff team that is committed, adequately supported and effective in providing a good standard of care to them. Sound recruitment practices ensure that service users remain in safe hands, while living at Russell Lodge. Improvement is required in the frequency of appraisals that are provided to staff. EVIDENCE: Six staff members remain in post at Russell Lodge and so the service users benefit from a small team that is generally committed to providing a good service to them. The registered manager is also directly involved in the daily delivery of care and so is able to support staff to achieve their objectives. There were two staff holding an NVQ Level 2 in Care, with two others currently undertaking the program. A minimum of two staff are on duty on day shifts with one person on night duty and an on call person is available to provide support in emergencies and as required. Most of the interactions and interventions observed were appropriate and service users were generally at the centre of all activities. The recruitment practices were examined and found to be robust. The registered persons are more than happy to retain interview notes to ensure transparency in their processes. Two references were in place for all staff and Russell Lodge DS0000025924.V354085.R01.S.doc Version 5.2 Page 21 Criminal Records Bureau reference checks were in place and appropriately carried out. One of the staff members interviewed confirmed that her employers carried out all the necessary checks as required by regulation and that she benefited from a detailed induction programme. She was also aware of the General Social Care Council’s code of conduct and the importance of this, in relation to her practice. It was not evident how service users were involved in the recruitment processes and some options were discussed with the registered persons. An organisational training and development plan was provided following the site visit, which mapped out the areas required for staff development and the development of the service. Dates were provided for training in; Dementia, Mental Capacity Act, Advanced Skills in Dementia, erudition Disability Awareness and Safeguarding Adults (refresher) training. Plans were in place for the registered manager to cascade person centred planning to the staff team. Feedback from staff indicated they were pleased with the level and quality of training that was given to them. External professionals expressed the view that staff were knowledgeable about the needs of service users and so, were in a good position to meet their needs. There was evidence to confirm that staff were having regular recorded supervision, which were in line with the national minimum standards for younger adults. This ensures that they not only meet their personal objectives, but also the aims and objectives of the service. However, there was little evidence of staff having annual appraisals, which could impact on their personal and professional development. It was clear that the registered manager had particular areas of development for staff, but it could not be evidenced in most cases outside of team meetings and supervision i.e. how the areas would be developed and monitored. Russell Lodge DS0000025924.V354085.R01.S.doc Version 5.2 Page 22 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) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Good management systems are in place to provide a quality service at Russell Lodge. This includes systems for record keeping, reviewing policies and procedures, and the promotion of health and safety in the home. More needs to be done in ‘quality monitoring’ to enhance the overall quality of services provided at Russell Lodge. EVIDENCE: The registered manager has been managing the service since 1999 and so has a good understanding of the service users’ needs. She is currently pursuing her RMA and has been on courses to keep abreast of the developments that are relevant to the field of learning disability. She has good support from the responsible individual and has the support of service users and their relatives and members of the staff team. The home is therefore operated from a strong and stable footing. Russell Lodge DS0000025924.V354085.R01.S.doc Version 5.2 Page 23 However, despite having a requirement at the last inspection around carrying out an internal audit of the service, there was no evidence that this was carried out. The registered persons must therefore carry one out without undue delay. There was evidence that the views of service users, staff, relatives and external professionals were acquired, but the information seems to be in most respects – lost. The most recent relatives survey was earlier in 2007, however the information from this and the internal audit should feed into an annual development plan for the service. This was not available at the inspection. There was evidence that regular monthly monitoring visits as required by Regulation 26 of the Care Homes Regulations 2001 – were carried out, which is positive. The health and safety policies and procedures and practices ensured that the home remains safe for all that use it. Risk assessments for all safe working practice topics were in place and service users were also involved in maintaining a safe environment. All staff had health and safety training and this starts at induction stage. A monthly health and safety audit is undertaken to identify any deficiencies, which are acted upon. Safety records for fire, gas and electricity were found in order. Records of accidents were maintained and the home was compliant with all the building, fire and environmental health regulations. Russell Lodge DS0000025924.V354085.R01.S.doc Version 5.2 Page 24 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 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 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 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 2 x x 3 x Russell Lodge DS0000025924.V354085.R01.S.doc Version 5.2 Page 25 YES 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. 1. Standard YA23 Regulation 13 Requirement Timescale for action 31/12/07 2. 3. YA36 YA39 18(2)(c) 24 The registered persons are required to apply robust measures to safeguard service users at all times by: 1) ensuring that residents’ monies are handled appropriately in the home and that full accountable records are maintained, and 2) ensuring that following the restraint of service users, appropriate checks are made, recorded and reported in line with safeguarding adults protocols. Action one (1) of this requirement was previously made with a timescale of 28/02/07. The registered manager is 31/12/07 required to carry out annual appraisals for all staff. The registered manager must 31/12/07 develop the homes quality assurance programme further to include, for example, an internal audit, and an annual development plan for the home must be available for inspection. The first aspect of this requirement was previously made with a timescale of DS0000025924.V354085.R01.S.doc Version 5.2 Russell Lodge Page 26 14/03/07. 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 YA17 YA23 YA34 Good Practice Recommendations The registered persons should develop menus in a userfriendly format. The registered persons should develop and/or review its policy on restraint/dealing with aggression in the home. The registered persons should explore ways of involving service users in the staff recruitment process of the home. Russell Lodge DS0000025924.V354085.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU 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 Russell Lodge DS0000025924.V354085.R01.S.doc Version 5.2 Page 28 - 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. 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