Inspection on 17/05/06 for Saxon Lodge

This inspection was carried out on 17th May 2006.

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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Saxon Lodge 16/05/07

Saxon Lodge 18/01/06

Saxon Lodge 04/10/05

Saxon Lodge 18/02/05

Saxon Lodge 13/08/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Saxon Lodge 20 Smith Street Shoeburyness Essex SS3 9AL Lead Inspector Claire Brookes - Nandara Key Inspection 17th May 2006 15:00 Saxon Lodge DS0000039678.V294221.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Saxon Lodge DS0000039678.V294221.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Saxon Lodge DS0000039678.V294221.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Saxon Lodge Address 20 Smith Street Shoeburyness Essex SS3 9AL 01702 295001 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) Southend on Sea Borough Council Miss Anne Boulton Care Home 13 Category(ies) of Learning disability (13), Learning disability over registration, with number 65 years of age (13) of places Saxon Lodge DS0000039678.V294221.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Care and accommodation to be provided to no more than 13 persons. Care and accommodation to be provided to persons between the age of 18 and 65 with a learning disability (LD). Care and accommodation to be provided to persons aged over 65 years who have a learning disability and who have resided in the home prior to their 65th birthday (LD(E)). 18th January 2006 Date of last inspection Brief Description of the Service: Saxon Lodge is owned and managed by Southend Borough Council. It is a purpose built establishment situated near to the main shopping centre of Shoeburyness and provides care to up to 13 adults with a learning disability. It is close to local amenities and has good local bus and train links to the area. The home offers single bed accommodation on the ground and first floor. Access to the first floor is by stairs, as a passenger lift is not available. There are two large lounge/dining areas on the ground/first floors. The home has its own car parking facilities to the rear of the property and there is some street parking available. Saxon Lodge makes information (including CSCI reports) available to prospective service users via their Service User Guide, their current service charges are £62.35 per week. Saxon Lodge DS0000039678.V294221.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place in May 2006. It was a Key Inspection, where the standards considered to be Key Standards were assessed. A sample of records and policies and procedures were inspected and a tour of the building took place. Staff, residents and visitors were spoken to. Prior to the site-visit, information was collated from the homes’ Pre-inspection Questionnaire, and put into the Inspection Record. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Saxon Lodge DS0000039678.V294221.R01.S.doc Version 5.1 Page 6 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 Saxon Lodge DS0000039678.V294221.R01.S.doc Version 5.1 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2&5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home assesses the individual aspirations and needs of prospective service users thoroughly. EVIDENCE: Before a prospective resident moves in, they are offered a series of social visits to the home where by they can meet the other residents and staff. Their relatives / representatives are invited along to talk to staff about any queries or concerns that they may have. An assessment of their abilities, along with any necessary risk assessments are made to ensure that the service can cater for the persons particular needs. Prior to admission a needs assessment is undertaken for each resident. This includes a thirteen-point “Individual Care Programme” including; Support required for personal hygiene, preferences within their daily routine, continence and special needs. Other needs such as special dietary requirements or support needed for mobilising are also carefully considered. The support plans list the residents’ individual abilities and needs. These are assessed and reviewed on a monthly basis. The home sets aims and objectives, which are designed for the staff to support the residents’ in their everyday lives. Saxon Lodge DS0000039678.V294221.R01.S.doc Version 5.1 Page 8 Resident likes and dislikes are documented in detail. The individual support plans also document the residents’ progress towards achieving their goals, and any positive changes that occur in their lives as a result. During the inspection a prospective service user was viewing the home with a family member. The resident is known by the new Manager of Saxon Lodge, and had been placed with her previously in another home in the borough. The resident had a tour of the premises and seemed to like the home. When asked if she would be happy to stay, she replied “Yes!” And smiled enthusiastically. Her brother commented that he knew some of the staff, and that they were all very good. The residents each have a contract held in their care plan. This is in a simple format, which is easy to follow. The information contained within the document is presented clearly and accurately. However not all residents are able to sign to acknowledge the agreement, so this may be done by their representative. Saxon Lodge DS0000039678.V294221.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home takes great care to ensure that the residents know their assessed and changing needs are reflected in their support plan. The residents are supported to make decisions about all aspects of their lives, and risk assessments are put in place where necessary, to help support the residents’ independence. EVIDENCE: The residents have a series of Care Needs Assessments. Each assessment consists of an aim, a goal for the individual, details of any support required, and a date for which the assessment should be reviewed. Reviews for each of the residents’ needs assessments happen on a monthly basis, where it can be decided whether the need has changed, been met, or whether continued support is required. Along with the Care Needs Assessments, there are guidelines in place for each resident including their preferences and how to deal with challenging behaviours. Residents are encouraged to be as independent as possible with support from the staff. Each day, the residents are given the opportunity to make decisions within their daily routines. For Saxon Lodge DS0000039678.V294221.R01.S.doc Version 5.1 Page 10 example, the residents are offered a series of choices, which the staff can facilitate. E.g., what activities would they like to do? What would they prefer to eat for dinner? The residents at this home are supported to take risks, in order for them to maintain an independent lifestyle. The home has Risk Assessments documented for each resident - for any potentially hazardous activity that they may undertake during their daily routines. Saxon Lodge DS0000039678.V294221.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home offers its residents’ a wide variety of activities. The residents are offered a good range of varied wholesome and healthy meals. The home needs to record the residents’ daily food intake in more detail. EVIDENCE: Individual preference is taken into account when staff plan activities. Activities such as discos, karaoke, games night, cinema trips and bowling are arranged, providing community access. Residents regularly attend appointments in the community, as well as visiting the local shopping centre and other places of interest such as the near by beach and parks. The relatives and friends of the residents are encouraged to visit the home where ever possible. Seating is provided in the residents’ rooms and quiet space is made available as necessary for any guests who may visit. Staff will also facilitate family contact outside of the home should it be requested. Saxon Lodge DS0000039678.V294221.R01.S.doc Version 5.1 Page 12 The residents’ weekly menus offer a choice of meals and meal alternatives, which are nutritionally balanced and healthy. Menus are planned in advance to ensure good organisation. The home also tries to turn everyday events into interesting activities. E.g. the home has themed dinners where the residents help decorate the dinning area and dress-up. One favourite is “Mexican Night” where Mexican food is served and banners are put around the room; residents wear sombreros and play maracas. Saxon Lodge DS0000039678.V294221.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents’ all receive good quality care, and the home always aims to meet the residents’ physical and emotional needs. Medications are stored and administered appropriately. EVIDENCE: There are currently two male and two female residents in the home, cared for by a mixed staff team. The residents are all encouraged to be as independent as possible with their personal care, whilst being supported by staff. Staff work closely with the residents in order to meet their physical and emotional needs. Key workers review the residents’ progress within the home on a monthly basis; a person-centred approach is used. Residents are encouraged to work with all staff. But if a resident preferes to receive personal care from a male or female member of staff in particular, then this is accomodated. Keyworkers work closely with residents to ensure that their physical and emotional needs are met. Time is taken to build trusting relationships, and keyworkers are close to their named resident. Contact with family and friends is encouraged. Their day-to-day physical needs are taken care of by staff, but outside proffesionals such as Occupational Therapy are contacted when required. One resident has recently developed a mild disability with his leg, an Saxon Lodge DS0000039678.V294221.R01.S.doc Version 5.1 Page 14 Occupational Therapist was brought in to assess him. He now has a perchingstool as an aid. The care plans contain details of s/u medications - name, dose, times, allergies and medical conditions. Medication Addministration Records ( MAR sheets) are kept in individual folders with the resident’s name, photo, keyworker, and GP listed. A key for colour coding on bubble packs is included. PRN protocols are recorded in each file. The MAR sheets contained no ommissions or inaccuracies. Saxon Lodge DS0000039678.V294221.R01.S.doc Version 5.1 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has clear guidance for staff contained within its protection and complaints policies and procedures, along with details of how to contact the Commission for Social Care Inspection. The home offers it’s staff training, but was unable to provide evidence that all staff training is up-to-date. EVIDENCE: During the last 12 months the home has received 1minor complaint from a resident. It was dealt with according to the homes Policies and Procedures within 28 days. Residents are provided with information published by the local authority named Comments, Complaints, Compliments. Which explains to the reader how they can contact their nearest Department of Social Services. POVA policies and procedures have not been reviewed since October 2002, and concerns and complaints policies and procedures have not been reviewed since September 2004. This is standard practise with Southend Borough Council, who provide, review and update all such documentation in the borough. All staff have read the homes’ abuse guidance policy and protection guidelines. The manager has had training for Protection of Vulnerable Adults. All staff have attended Adult Protection training, but some staff training appeared to be outof-date. The home was unable to prove that staff training is up-to-date or provide evidence of all of the courses attended by staff. Saxon Lodge DS0000039678.V294221.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 28 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a safe and homely environment. Residents’ bedrooms reflect their individuality. Shared spaces are accessible to residents and comfortable. The home is clean and hygienic. EVIDENCE: The home is decorated and furnished to a good standard. The kitchen is large and modern. It has been designed so that residents can help to cook and prepare meals, and take part in baking activities. Each resident has a separate bedroom and this is decorated to their taste and personalised with familiar objects and photographs. One resident was keen to show me her room, she was very proud of it. Its mine she said. The walls are decorated in pink, with glittery pink and purple butterflies and dragonflies along the wall. Saxon Lodge DS0000039678.V294221.R01.S.doc Version 5.1 Page 17 The lounge and dining room provide communal space that is easily accessible to the residents and comfortable and homely. There is a laundry room, which is separate from the kitchen both of which are kept clean and hygienic. Saxon Lodge DS0000039678.V294221.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home does not always have an effective system in place for evidencing the staffs’ training course attendance. Staff receive a good level of support and supervision within the home. Residents are supported by robust recruitment policies and practices. EVIDENCE: The home has a comprehensive range of policies and procedures in place, which are updated by Southend Borough Council. Staff members have not evidenced that they have read and understood these policies. The home has the resources to offer its staff a range of mandatory and supplementary training courses throughout the year. However, as the manager is new to post she is currently in the process of finding a way to record which courses each member of staff has undertaken. As a result she was not always able to clearly evidence how many staff have up-to-date training. Staff spoken to say that they enjoy their job, and feel very much supported within their role. Staff recruitment files were assessed. They evidenced that the homes’ manager provides staff with regular supervision on a monthly basis. All staff had two written references, reliable sources of identification and a clear Criminal Records Bureau check. Saxon Lodge DS0000039678.V294221.R01.S.doc Version 5.1 Page 19 Saxon Lodge DS0000039678.V294221.R01.S.doc Version 5.1 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The day-to-day running of the home is very well organised, and resident centred. Staff and residents are protected by good health and safety practices inside the home. EVIDENCE: The home is well run, and residents are encouraged to contribute towards their daily routines. Some residents’ are non-verbal, but staff have found their own ways to communicate with them, and there for understand their likes and dislikes. All aspects of the service are designed to cater for each of the residents’ preferences and needs. Staff and residents alike are aware that should a new or changing need arise for anyone, that the team would do what they can to support it. Residents meetings are held every 4-6 weeks, and the home carries out its own annual quality assurance questionnaire, which is sent to each resident, their families / representatives, staff and other professionals. The results of the survey are collated in a report, which is used to evaluate the service. Saxon Lodge DS0000039678.V294221.R01.S.doc Version 5.1 Page 21 All required health and safety checks have been carried out and are up-todate. The home has a range of 41 policies and procedures in place to protect the residents and staff. Staff have knowledge of policies and procedures within the home, and they are kept readily available in the main office for staff to access. The majority of the homes policies and procedures have not been reviewed since September 2004 under Southend Borough Council guidance, and staff have not evidenced their acknowledgment of the homes’ policies and procedures. Saxon Lodge DS0000039678.V294221.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 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 3 X X 3 X Saxon Lodge DS0000039678.V294221.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA23 Regulation 18(1)(c) Requirement The registered manager must ensure that the home has a training and development plan, dedicated training budget, and designated person with responsibility for the training and development programme. This refers to the home’s inability to evidence that all staff have attended POVA training. The registered manager must ensure that the home has a training and development plan, dedicated training budget, and designated person with responsibility for the training and development programme. This refers to the home’s inability to evidence that staff have undertaken sufficient and up-to-date mandatory training. Timescale for action 17/08/06 2 YA35 18(1)(c) 17/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Saxon Lodge DS0000039678.V294221.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG National Enquiry Line: 0845 015 0120 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 Saxon Lodge DS0000039678.V294221.R01.S.doc Version 5.1 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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