Inspection on 15/05/07 for Sennen Lodge

This inspection was carried out on 15th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sennen Lodge 13/05/08

Sennen Lodge 22/01/07

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 Sennen Lodge Kanes Hill Southampton Hampshire SO19 6AJ Lead Inspector Christine Walsh Unannounced Inspection 15th May 2007 10:00 Sennen Lodge DS0000067982.V335997.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 Sennen Lodge DS0000067982.V335997.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. Sennen Lodge DS0000067982.V335997.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sennen Lodge Address Kanes Hill Southampton Hampshire SO19 6AJ 01329 829 128 02380 472 361 manager.sennen@truecare.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) Truecare Group Limited Mr Andrew Harris Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Sennen Lodge DS0000067982.V335997.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd January 2007 Brief Description of the Service: Sennen Lodge provides care and support to up to eight young men with autism. It is a large detached two-storey property situated in a semi-rural position on the outskirts of the city of Southampton, with reasonable access to local facilities. Whilst large, the building is domestic in nature and provides eight single bedrooms each having its own en-suite facility of bathroom and toilet. On the ground floor are a lounge/dining area and a small ‘quiet area’, together with an activity room and sensory room. The home’s kitchen, laundry and staff office are also all located on this floor. There is access to the rear patio and garden, which contains a summerhouse. Car parking for several vehicles is available immediately to the front of the property. Sennen Lodge DS0000067982.V335997.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit formed part of the key inspection process and was carried over one day by Mrs C Walsh, regulatory inspector. An Annual Quality Assurance Assessment (AQAA) document was sent to the home eight weeks prior to the visit with a date for it to be returned to the Commission for Social Care Inspection, in addition “Have Your Say” resident and relatives comment cards were sent, but neither the AQAA or any comment cards were received. Following the last visit to the home the service was required to provide an improvement plan this also was not received. A tour of the home took place with the assistances of the residents who were happy to allow us to view their bedrooms rooms. Therefore information obtained to inform this report was based mainly on speaking with the newly appointed manager, operations manager, the director and staff and observation of staff’s interactions with residents. What the service does well: What has improved since the last inspection? Following the last visit to the home it was issued with eight requirements all eight of these requirements have been met. Sennen Lodge DS0000067982.V335997.R01.S.doc Version 5.2 Page 6 The manager has improved the assessment process to ensure it can meet prospective residents needs and the assessed needs of the current residents are now kept under review and changes made to their plan of care where required. The manager and staff have done well to develop structured days/plans which predominately include activities of the residents choosing or their known interest. This has led to a drop in challenges presented by the residents and staff feel more confident in working with the residents. The home supports residents with their medication, undertaking safe administration practices and clearly recording when and at what time the residents have taken their medications. This is an improvement from the last visit where records did not clearly show that residents were receiving the correct medication at the correct time. Since the previous visit to the service all staff have now received adult protection training and staff who were spoken with could clearly state what they would do if they witnessed an abusive act taking place. The home is currently sufficiently staffed to meet the current needs of the residents, the managers are aware that with the admission of new residents and when they are at full capacity of eight residents they will need to increase staffing levels. At the time of the last visit the inspector could not gain access to staff information. The company has an agreement with the Commission for Social Care Inspection to hold staff information centrally, however the home must still hold information that demonstrates appropriate employment checks have been taken out on staff prior to working in the home, these documents were found to be in place. Following the last visit to the home it was found that accident records were not being appropriately completed and logged which breached confidentiality and the dignity and privacy of the residents. The manager could demonstrate that this area of safe recording and record keeping has improved. In addition to meeting the listed requirements the managers spoke of other improvements that have been made to the management, its management structure and staffing confidence all of which are reflected in the body of the report. Comments from staff: “Things have improved a lot over the last couple of months, the residents seem happier and I feel better supported”. “The training I have received over the last couple of months has helped me a lot to understand the residents and I feel a lot more confident”. Sennen Lodge DS0000067982.V335997.R01.S.doc Version 5.2 Page 7 “I have a lot of respect for the new manager, he is doing a lot to improve the quality of life for the residents”. “The support and supervision I receive from the manager on a day-to-day basis has helped me to support the residents confidently”. 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. Sennen Lodge DS0000067982.V335997.R01.S.doc Version 5.2 Page 8 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 Sennen Lodge DS0000067982.V335997.R01.S.doc Version 5.2 Page 9 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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home does well to undertake a thorough assessment process to ensure it can meet prospective residents needs. EVIDENCE: As part of the inspection process both the manager and operations manager were spoken with. The home currently has four male residents and has the capacity to take up to eight residents. Following the last visit to the home concerns were raised with the level of information the home was obtaining prior to admitting new residents to the service. This process has changed significantly and the managers spoke of the current assessment work they are undertaking to support a prospective resident to enter the home. Sennen Lodge DS0000067982.V335997.R01.S.doc Version 5.2 Page 10 The manager spoke of the structured transition of a prospective resident and how regular meetings are taking place with the involvement of the relatives, social services and relevant health care professionals. The people involved have jointly agreed a transition plan, which includes staff from the prospective residents previous placement supporting and working along side staff who work in the home. The staff working in the home will visit the prospective resident in his current placement and day and evening activities to observe interactions and behaviours and how his needs are met. The prospective resident will then visit the home to meet with current residents and staff and have an opportunity to familiarise himself with the environment. It is at this point the manager said that he and the staff will observe for compatibility with other residents and assess any changing needs or behaviours, develop the residents personal plan and hold a review meeting at the end of a four-week trial period. Sennen Lodge DS0000067982.V335997.R01.S.doc Version 5.2 Page 11 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 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is in the process of reviewing and developing personal plans that will reflect the assessed and changing needs, and personal goals of the people who use the service. The area of supporting people who use the service to make choices, decision and develop independent life styles within a risk management framework has improved. EVIDENCE: As part of the inspection process the inspector spoke with the manager, operations manager, staff and observed daily activity and interactions with residents. Each resident has a personal plan, which holds personal information about the residents such as DOB and NOK details and care plans that provides staff with Sennen Lodge DS0000067982.V335997.R01.S.doc Version 5.2 Page 12 information about how the residents wishes and needs to be supported. The manager confirmed that the personal plans along with some risk management guidelines were still in the process of being reviewed but felt that this process would be completed within the next couple of months. The manager is also advised to revisit the information held in the personal files so staff can easily follow and use the file as a daily working tool. A long discussion took place regarding person centred planning and how the home takes on board the philosophy behind the practice and how it is starting to be used in the home such as life mapping with one of the residents and a move towards supported living for another. As part of improving the quality of the service to the residents and develop the staffs understanding of the complex needs and challenges presented by the residents the managers are focussing on improving communication systems and tools within the home. Staff are currently receiving Makaton training several times a week, picture prompt cards are used for some residents and the activites coordinator spoke of his plans to improve the weekly activity board to make it more accessible for the residents. A member of staff spoke of how beneficial she has found the training and watching others communicate with the residents. The managers spoke of how they are working hands on and leading by example for staff ruling out bad practices and instilling the philosophy of the home onto the staff. The staff who were spoken with appeared aware of the importance of providing valuing opportunities and experiences and to support the residents to make choices and decisions about their daily lives Due to the complex nature and behaviours of the residents a structured day has been developed with each resident, which includes supporting where necessary the residents with personal care, daily life skills and daily activities. Within this structured day residents are supported to make choices and decisions and negotiation forms an important part of this process to support the residents to function safely. This was observed at the time of the visit and the negotiation between the resident and staff supported the resident to make an informed choice and prevented rising anxieties to escalate further. This overall risk management approach is paying off and is demonstrated with less incidents of challenging behaviour. Sennen Lodge DS0000067982.V335997.R01.S.doc Version 5.2 Page 13 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 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sennen Lodge is an active and lively home where improvements to the daily lives of the people who use the service have been made. The implementation of a structured day for each person provides opportunities for them to engage in a variety of community, age appropriate and peer, social and leisure activities, and maintain and develop relationships with others. The home provides a healthy and well balanced diet for the people who use the service. EVIDENCE: As part of the inspection process the inspector viewed residents individual structured days, spoke with managers, staff and a resident. Sennen Lodge DS0000067982.V335997.R01.S.doc Version 5.2 Page 14 Since the previous visit to the home significant changes have been made to how residents are supported to engage in valuing activities which are in the main of their choice, these include daily life activities to more adventurous activities such as horse riding and wall climbing. The introduction of an activities coordinator has assisted greatly in the development of accessing alternative activites and more structure to the resident’s days. At the time of the visit residents were involved in a variety of activites such as shopping for groceries, using the computer room and accessing activities outside of the home. The home has separate sensory, computer, art and quiet rooms. The activities coordinator has future plans to improve the use of these areas and the garden, which needs landscaping. The activities coordinator spoke of encouraging the residents to be involved in these plans. A member of staff said: “Weekends are laid back and we ask the residents what they want to do, we go to places like Clarence Pier, Windborne Market, walks and the cinema” The resident’s bedrooms are equipped with electrical equipment such as TV’s, stereos and computers and personal items of interest to the individual resident. Evidence of individual art projects are displayed in communal areas and individual bedrooms. A resident proudly showed off his room and confirmed that he liked the daily activities in is involved in and that he helps to tidy his room. The manager spoke of how the service hopes to support the residents to attend more peer and age appropriate activities and how he has just learnt of a local club for people with Autism, which he hopes to encourage some of the residents to attend. Through discussion it was established that residents maintain relationships with their relatives and how with joint working with relatives the home and specialist health care professionals are aiming to work towards a consistent approach for the residents, especially for those who regularly go home for day and weekend visits. The manager’s spoke of how the home respects but at the same time safeguards the sexual interests of the residents. The managers explained they have provided staff with guidance, which involves monitoring residents, and have involved a psychologist to assist with assessment and ethical issues. All the residents are encouraged to eat healthily and take regular exercise, a member of staff spoke of how residents are encouraged to plan the menu, take Sennen Lodge DS0000067982.V335997.R01.S.doc Version 5.2 Page 15 turns in shopping and helping to prepare meals. A displayed menu plan demonstrates that a healthy and well-balanced diet with freshly cooked foods is provided for the residents. Cultural and specific likes and dislikes are respected and considered when planning the menu. Built into the structured day are regular breaks where residents and staff to sit together, staff also sit with the residents at mealtimes but for some eating together proves difficult for them so the home is looking at how they can improve the this area including the time, environment and noise. Sennen Lodge DS0000067982.V335997.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 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is working towards a person centred approach to ensure the people who use the service are supported with their personal care in the way that they wish. Positive relationships with health care providers ensure the people who use the service have their physical and emotional health care needs met. The home has safe systems in place to support the people who use the service with their medication. EVIDENCE: As part of the inspection process the inspector spoke with the managers, staff a resident and observed interactions and practices between staff and residents. The development of a structured plan/day involves assistance with personal support and daily living skills. The structured plan/day has been developed by Sennen Lodge DS0000067982.V335997.R01.S.doc Version 5.2 Page 17 obtaining information from the residents, their relatives and staff who already know the residents. The managers are aware the plans are in their early days and will need regular monitoring and reviewing. A discussion took place with the managers and on a separate occasion with a member of staff about the difference between providing choices and the homes responsibility to consider their duty of care. The managers spoke of how staff initially struggled with understanding the complex needs of people with Autism, the importance of a structured day with clear boundaries and stimulus against allowing someone to stay in bed all day without tending to their personal care and wellbeing. On the day of the visit staff were observed following clear guidelines to support a resident to get up, this is when a member of staff said she understood both the importance of choice and duty of care to the resident but how hard it was to motivate the resident to get up. The manager agreed further work was required with staff, which would involve leading by example. Through the course of the visit it was established that the home has good relationships with all health care professionals and has regular contact with the companies psychologist and phycaritrist. The latter being heavily involved in monitoring the behaviours and mental health needs of the residents and providing guidance for staff. The manager spoke of the good relationship with the local GP surgery and information provided in residents personal plans provided evidence that residents receive regular check ups with the dentist and where required chiropodist. The home supports the residents with their medication, which is administered by staff and safely locked away. The home uses a monitored dossett system (MDS), which is dispensed by a well-known high street pharmacist. The home keeps copies of the prescription and records medication received and returned. Following the last visit to the home it was found that records were incorrect and it could not be established if medications has been administered as required. An improvement has been made in this area and staff have received training, however an administration error was found of which the manager could clarify what had happened. The manager must ensure all staff are aware of the roles and responsibilities and the importance of ensuring the residents receive the right medication at the right time and does. The manager spoke of the regular reviews of the resident’s medications and how in some cases anti-psychotic medications were being reduced. Another indicator of how the home has improved its approach to managing the challenges presented by the residents. Sennen Lodge DS0000067982.V335997.R01.S.doc Version 5.2 Page 18 The residents who currently receive as required (PRN) medications such as paracetamol do not have a care plan in place to describe to staff when to give it to them, this is especially important for those residents with limited communicate skills. The manager agreed to develop individual PRN care plans. Sennen Lodge DS0000067982.V335997.R01.S.doc Version 5.2 Page 19 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 and 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 made improvements to safeguarding the people who use the service from potential risk of abuse, but could do better to support them to air their views and concerns. EVIDENCE: As part of the inspection process the inspector viewed the homes complaints procedure, spoke with staff and the managers and observed interactions between residents and staff. The home has a complaints procedures that clearly states how people who use the service can make a complaint, the timescale for responding and the name and address of the local Commission for Social Care Inspection office, who can be contacted if the complainant is not happy with the outcome of a complaint they have made. A discussion took place on how residents with complex communication needs express their views and concerns and what the home could do better to consider how they can provide them with accessible communication aids that will assist them to express their views and concerns appropriately rather than through inappropriate behaviours. The manager said he would consider this carefully and is aware that further improvements are required in the area of communication. Sennen Lodge DS0000067982.V335997.R01.S.doc Version 5.2 Page 20 The staff who were spoken with were very clear about what they would do if a resident made a complaint, they knew where possible to try and resolve the complaint, inform a senior member of staff and record details of the complaint immediately. Since the last visit to the home all staff have received abuse awareness training and valuing people training which includes the principles and philosophy of care. Staff spoken with at the time of the visit confirmed they had received the training and could feedback clearly what they considered constituted abuse and who they would report this to. The manager spoke of how the implementation of a structured day/plan has reduced the level of challenges presented by the residents; he said residents are more stimulated and involved in their environment with opportunities to explore new activities and daily life skills. The staff confirmed they had seen a reduction also. The manager spoke of how they are moving away from physical restraint, using a proactive and passive response to first signs of agitation or noticeable trigger. He spoke of some of the positive intervention strategies already in place including negotiation. This appears to have had a positive affect on staff who appeared comfortable, relaxed and stated they were more happy to go out and work with the residents. The manager recognises the move form physical restraint to a proactive passive support will require training and significant cultural change for the staff. Sennen Lodge DS0000067982.V335997.R01.S.doc Version 5.2 Page 21 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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who use the service live in a homely, comfortable, welcoming and spacious environment. Each person has a bedroom of their own which is clean and personalised to reflect their personalities, lifestyles and needs. The home is kept clean and tidy throughout which minimises the risk of infection. EVIDENCE: Sennen Lodge is a large spacious home, which has been furnished and decorated to a high spec modern standard. A large communal lounge/dining room sits in the centre of the home, with spacious kitchen, separate quiet room, computer room, craft room and sensory room running off of it. Sennen Lodge DS0000067982.V335997.R01.S.doc Version 5.2 Page 22 The home has an enclosed garden with decked patio area and sun house. The activities coordinator spoke of the plans to landscape the garden and provide garden activity equipment for the residents. This is to be achieved with assistance from the residents once the weather improves. Bedrooms are situated on both floors of the home and each resident has a room of their own with en suite facilities. A resident spoken with at the time of the visit said he liked his room and had chosen the colours. All the resident’s bedrooms are roomy and individualised to reflect their personalities and hobbies and interests. The home is kept clean and tidy by staff with the assistance of the residents. The kitchen and communal areas were particularly clean and evidence of environmental health guidance and practice was observed in the safe storage and handling of food. In addition staff are provided with appropriate clothing to support residents with their personal hygiene and there are set days when the residents are supported to launder their clothes. The home has an industrial washing machine that can sluice and wash to high temperatures if required. The manager when asked confirmed that not all staff had received infection control training the manager is advised to place staff on this training to ensure all staff are aware of what to do to minimise the risk of cross infection. The manager is also advised to ensure his staff are appropriately dressed to undertake their roles and responsibilities, long nails and excessive jewellery are a source for germs and pose a potential hazard to both residents and the staff member. Sennen Lodge DS0000067982.V335997.R01.S.doc Version 5.2 Page 23 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 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is doing better to improve the quality and standard of care and support it provides to the people who use the service. The home does well to support and protect the residents by using robust recruitment policies and procedures EVIDENCE: As part of the inspection process the inspector viewed staff duty rota, staff recruitment and training records and spoke with the managers and staff. The home is currently supporting four residents and demonstrates that it has sufficient numbers of staff to meet their current needs. Over the course of the day of the visit nine staff were rostered to be on duty including the manager, the activities coordinator and night staff. Sennen Lodge DS0000067982.V335997.R01.S.doc Version 5.2 Page 24 The staff were observed to go about their daily tasks supporting the residents and housework and daily administration in a relaxed and unhurried way. A member of staff said the allocation of staff responsibilities had much improved since the new manager started in post and all staff now know what resident they are allocated to each day. The manager said they has assisted with the continuity of care, improved communication and lessened the number of challenges from the residents. A member of staff said: “I feel more confident working with the residents now and I am even happy to go shopping with them on my own”. Some discussion took place regarding the lack of activity in the evenings and the current restriction of three staff did not enable the residents to go out in the evening if they wished. This was discussed with the managers who said currently they are working on getting day activites right for the residents and will in the very near future be more creative on how they allocate staff and appoint more staff if required. Following the last visit to the home it was required to ensure staff files were accessible in the home. The company has an agreement with the Commission for Social Care Inspection (Annex 4) to hold staff personal recruitment details centrally, but provide evidence that appropriate checks had been taken out. Four staff records were viewed one of which was the manager and an existing member of staff who previously worked in another home and two recently appointed staff, all documentation demonstrated that the company had undertaken a robust recruitment procedure. This was confirmed by two staff who said they had completed an application, attended an interview, provided two references and identification so a criminal record bureau (CRB) and protection of vulnerable adult (POVA) check could take place. The staff spoken with at the time of the visit confirmed that they had received sufficient training to support them to meet the complex needs of the residents including Autism training, communication including Makaton, control and restraint and mandatory training such as food hygiene and fire safety. A new member of staff who has been working in the home approximately three months said she had completed her Learning Disability Award Framework induction course and is going to start a national vocational award (NVQ2) in September this year. None of the staff have received moving and handling or infection control training therefore the manager is advised that staff receive this training to prevent the risk of harm to the residents and themselves. Sennen Lodge DS0000067982.V335997.R01.S.doc Version 5.2 Page 25 The managers spoke of the move away from using control and restraint to passive response and touch support, they are aware this will be a big cultural change for residents and staff and careful consideration will be made to how the service meets this need. Staff confirmed that they feel well supported by the new manager and there is evidence of supervisions taking place. The manager said he has an open door policy and works along side his staff providing a role model of good practice and support to them. Sennen Lodge DS0000067982.V335997.R01.S.doc Version 5.2 Page 26 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 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements to the way the home is managed is beginning to benefit the people who use the service. The home must consider how it can obtain the views of the residents, relatives and others to improve the quality of service it provides. The manager and staff in the main protect the health, safety and welfare of the residents. EVIDENCE: Sennen Lodge DS0000067982.V335997.R01.S.doc Version 5.2 Page 27 As part of the inspection process the inspector met with and observed the managers administration and management practices, sought the views of his managers and staff and viewed health and safety documents. The service has recently appointed a new manager to the home who has transferred from another home within the service and who has many years experience working with people with learning disabilities and mental health needs. The manager admitted to not working with people with Autism before but knows how to apply the principles of care and where to source help when required. The operations manager said he has worked closely along side the manager and gave praise for the hard work and commitment he has shown since starting at Sennen Lodge. Due to the homes previous history of poor management and structure for residents and guidance for staff the current managers have concentrated their efforts on providing a safe environment for the residents to live and staff to work, this has meant prioritising some areas of management and administration focussing on developing a structured day/plan for the residents and providing support and training for staff. The staff spoke highly of the manager and how in a short period of time he has developed the trust of the staff and some of the residents. A member of staff said: “we have a good manager, he is very visible, knows what’s going on and is there to help you when you need him”. The home has not been open a year and therefore a quality review has not taken place. At the time of the visit the registered responsible individual was made aware that the Annual Quality Assurance Assessment (AQAA) had to be completed and returned to the Commission for Social Care Inspection. The manager was advised to use the tool as a starting point to assessing the quality of the service and think how they can obtain the views of the residents and others who have an interest in the service. The manager said he holds weekly meeting with staff and residents are welcome to join them if they wish. Following the previous visit to the home accident records were not being completed correctly and were not being appropriately stored. Evidence showed that an improvement has been made in this area and records describe clearly the incident detailing what happened before, during and after the incident and who was involved. Sennen Lodge DS0000067982.V335997.R01.S.doc Version 5.2 Page 28 At the time of the visit Environmental Health Officers and health and safety managers from the company were visiting the home to meet with the manager and staff who had recently been injured whilst supporting residents. The outcome of the visit was that staff must receive managing challenging behaviour training with in the first month of commencing in the home and must not get involved in the support of residents who are displaying challenging behaviour. All serviceable utilities were noted to be in date of servicing and fire records were being maintained other than weekly checks on fire alarms which were not taking place, therefore the manager must ensure who ever is responsible for fire safety undertakes the check of fire alarms weekly. The manager spoke of a recent drill where two residents refused to leave the home. The home must ensure the new fire safety legislation introduced in October 2006 in respect of fire risk assessments is undertaken to ensure residents are not placed at risk from fire and the fire brigade are issued with a plan of the home and details of the residents specific needs. The manager must address the closure of the fire doors to the kitchen and office which slam shut very quickly and loudly, not only is this a trapping hazard it is a potential trigger for residents with sensitive hearing. Fire records evidenced that staff have received fire safety training Sennen Lodge DS0000067982.V335997.R01.S.doc Version 5.2 Page 29 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 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 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 2 X 3 X 2 X X 2 X Sennen Lodge DS0000067982.V335997.R01.S.doc Version 5.2 Page 30 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 YA20 Regulation 13(2) Requirement The staff must be provided with guidance on when to give “as required” medications (PRN) to ensure the residents receive their medication when they need it. Timescale for action 30/06/07 2. YA22 22 The home must consider how it 31/07/07 supports the residents to express their views and concerns. Staff must receive training in 31/07/07 moving and handling and infection control to prevent harm and risk of injury and infection to the residents and themselves. To prevent injury from fire the home must ensure all fire procedures and checks are followed as per the Fire Safety Regulations. Weekly checks must be undertaken on fire alarms. 30/06/07 3. YA35 18 13(4) 4. YA42 23(4) 5. YA42 23(4) The home must seek advice of the Hampshire Fire and Safety in respect of the homes fire risk assessments to ensure all areas DS0000067982.V335997.R01.S.doc 30/06/07 Sennen Lodge Version 5.2 Page 31 of the home have procedures in place to prevent injury to the residents and staff. 6. YA42 23(4) The home must ensure that fire doors meet the current legislation in respect of closure to prevent a trapping hazard and excessive noise. 30/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Sennen Lodge DS0000067982.V335997.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Sennen Lodge DS0000067982.V335997.R01.S.doc Version 5.2 Page 33 - 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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