Inspection on 22/01/07 for Sennen Lodge

This inspection was carried out on 22nd January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 8 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 15/05/07

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Dalewood Respite Care

Orchard,The

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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 Keith Hopkins Unannounced Inspection 22nd January 2007 12:00 Sennen Lodge DS0000067982.V328822.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.V328822.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.V328822.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 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.V328822.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection N/A Brief Description of the Service: Sennen Lodge 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.V328822.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Four and three quarter hours were spent visiting the home, during which time the opportunity was taken to look around the property, view records and policies and to talk to four members of staff. The inspector was only able to communicate in a limited way one service user himself but did observe staff responding to expressed needs and interacting with service users in a professional yet friendly manner. Fees are £2,092 per week. 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. The summary of this inspection report can be made available in other formats on request. Sennen Lodge DS0000067982.V328822.R01.S.doc Version 5.2 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 Sennen Lodge DS0000067982.V328822.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Assessments of current service users were undertaken prior to admission although these were insufficiently detailed to enable the home to subsequently meet all service users’ needs. EVIDENCE: Three service users’ files were inspected and needs assessments seen within these. In one case this comprised a behaviour support plan from the service user’s previous placement. A second file contained personal details including, for example, details of the need to prevent self-injurious behaviour and of the need for the service user to be supported by a male member of staff at all times. This file also contained an undated, unsigned piece of paper with comments such as ‘no meds’, ‘baths not shower’ and ‘very violent with parents’. The inspector was informed that since the home opened in August 2006 one service user had moved elsewhere as Sennen Lodge could not adequately meet his needs. A second service user had been given notice and was expected to be moving elsewhere shortly for the same reason. Sennen Lodge DS0000067982.V328822.R01.S.doc Version 5.2 Page 8 The registered person needs to ensure that in the event of any future admissions taking place a full assessment of needs takes place prior to consideration of an admission. Sennen Lodge DS0000067982.V328822.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 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a care planning regime, which identifies service users’ needs. Identified personal and health care needs are, in the main, met. EVIDENCE: Care documentation relating to three service users was examined. There were details of continuing personal and health care needs together with some details of the support needed to meet such needs. An index to the contents of each file, the ‘Service User Folder Format’ listed what was expected to be in the file. This included, for example, the service user’s personal details, current reports and assessments, and a monthly evaluation sheet. None of the files contained all of the listed information. For example, one file contained information relating to a review that had been undertaken in November 2006. A second file had no evidence that any reviews Sennen Lodge DS0000067982.V328822.R01.S.doc Version 5.2 Page 10 had taken place and the third contained evidence that one review had taken place but this was incorrectly dated for July 2007. Files contained an adequate level of detail to enable staff to meet assessed needs. There was, for example, information regarding communication, emotional health and personal care. There was also information regarding medical needs together with more specific details such as, for example, whether the service user had any allergies. Risk assessments about meeting care needs were in place in two of the files examined but not the third. Service users are supported in planning some personal goals such as, for example, the development of skills to complete household tasks and to deal with personal hygiene. The inspector noted that records are kept on a daily basis detailing progress made towards meeting these goals. Service users were observed during the inspection to be supported in making some decisions about day-to day activities, assisted by staff when this was necessary. Sennen Lodge DS0000067982.V328822.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 and 17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users have varied lifestyles and undertake activities of their choice within the home. Some activities are undertaken in the local community although not all planned activities happen. Service users enjoy a varied and healthy diet. EVIDENCE: The inspector examined individual activity plans for two service users. These indicated that activities were varied and included, for example, arts, cooking for fun and developing IT skills. There were also indications that service users were supported in developing personal skills such as keeping their rooms clean and tidy. A third service user was said not to have a specific plan, but that his main interest was in going for walks. Service users have access to a secure garden to the rear of the property with a summerhouse. Sennen Lodge DS0000067982.V328822.R01.S.doc Version 5.2 Page 12 Various activities, such as swimming, going to a gym and going for walks were planned to be undertaken in the community on an individual basis. On the day of the visit one service user’s plan indicated that he was due to go swimming and a second plan that the service user was to go to the gym. However, the inspector was informed that there was an insufficient number of staff on duty for either of these activities to be undertaken. The home employs a member of staff on three weekdays whose role is dedicated to providing additional specialist support to service users in undertaking individual activities ‘in-house’. Service users also have access to a sensory room. The person in charge explained that the personal circumstances of most service users were such that there was limited contact with relatives although they were welcome to visit at any time. One service user was, however, able to stay at the family home at weekends. Although the inspector did not on this occasion see a meal being served, menus indicated a variety of meals being available. Service users’ dietary needs are known to staff and met. One service user, for example, was said to enjoy a more ‘Mediterranean’ type diet and there was evidence that the home was meeting this need. Sennen Lodge DS0000067982.V328822.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides degrees of personal support to service users to address personal, health care and medication needs. The home is not currently always providing personal care to service users by a staff member of the same gender. EVIDENCE: Staff were observed to be supporting service users in undertaking some dayto-day activities in a professional yet friendly manner. Service users were dressed in casual clothes and were tidily groomed. When staff needed to provide support in undertaking activities of a more personal nature this was done in private. The inspector was informed that there was good access to a local GP surgery and that a good level of service was given. Their was a choice of a male or female GP and an instance was quoted where a GP left the surgery to attend to a service user outside when the service user was reluctant to get out of the car. Sennen Lodge DS0000067982.V328822.R01.S.doc Version 5.2 Page 14 The person in charge explained that service users were all registered with a dentist and that appointments were made with other health professionals such as the optician and chiropodist as necessary. One service user, for example, was shortly to be supported in making an appointment with the optician. The home has a policy and procedure for staff to follow regarding the dispensing of medication. There is a monitored dosage system in place and the inspector checked medication for two service users against medication administration records. The record relating to one service user was in order and up-to-date. The inspector noted that a tablet for one service user had not been taken on 7th January. The medication record for the period covering this date could not be located, there being no explanation as to why this medication was still in the blister pack. It was not possible to confirm that staff dealing with medication had been trained to do so as staff records were not available. Sennen Lodge DS0000067982.V328822.R01.S.doc Version 5.2 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. 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. Service users are protected through policies and procedures for dealing with complaints and suspected abuse, although it is understood that not all staff have yet been trained in adult protection. EVIDENCE: The home has a complaints policy and procedure, which contains an appropriate timescale and which staff spoken with were aware of. The inspector pointed out to the person in charge that the information regarding complaints displayed on the home’s noticeboard was out of date, referring to the previous regulatory body. The home also has a policy and procedure relating to adult protection. Those support workers interviewed knew what to do in the case of suspected abuse, saying that they would report this to a more senior person. It is understood however that not all staff had yet been trained in adult protection. Sennen Lodge DS0000067982.V328822.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides a safe, clean and hygienic environment. Service users’ stimulation and enjoyment of their surroundings could be enhanced. EVIDENCE: The tour of the building showed this to be clean throughout and there were no undue odours. Communal areas had functional but adequate furniture which service users were seen to be using. Given the nature of service users’ challenging behaviours some facilities such as the kitchen remain locked until access is needed. The inspector was informed that it was not possible for service users to access the kitchen for reasons of personal health and safety. Two service users’ bedrooms were inspected and were adequate in size. There had been some personalisation of these rooms, and evidence that they were Sennen Lodge DS0000067982.V328822.R01.S.doc Version 5.2 Page 17 accessed on occasion when service users chose not to make use of the communal areas. The home’s laundry arrangements are domestic in nature with a utility room on the ground floor housing a washing machine and dryer. There was some indication of some damage to the fabric of the building as a result of service users’ behaviours, with some areas, for example, requiring repainting. The inspector was informed that repairs to some damage to a bedroom door were awaited. There were no immediately obvious hazards to health and safety noted by the inspector during the tour of the building. The COSHH cupboard, for example, was locked and information sheets relating to chemical products were available. Sennen Lodge DS0000067982.V328822.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users are placed at some risk though current staffing arrangements. The inspector was unable to access full staff records so the home was unable to fully demonstrate the soundness of its recruitment process; neither was it able to confirm that staff were adequately trained to meet service users’ needs. EVIDENCE: The person in charge informed the inspector that in the absence of the home’s manager no staff files were available as they were in a locked cabinet to which no-one on duty had access. This meant that the inspector was unable to confirm the adequacy or otherwise of the home’s recruitment procedure and of its subsequent protection of service users. Training undertaken by staff could not be confirmed although there was an indication on a ‘whiteboard’ in the office that staff had received some training. It appeared, for example, that some eight out of sixteen staff had received Health and safety training, that nine had received training in Control and Restraint and seven in Medication. Sennen Lodge DS0000067982.V328822.R01.S.doc Version 5.2 Page 19 Staff spoken with were anxious to provide a good service but felt that they could have been better prepared and supported during the home’s initial period of operation, citing the need for more specialist training in dealing with autistic behaviours. The home’s rota generally allows for there to be five support workers on duty at any time during the day, although it was reported to the inspector that the current needs of service users were difficult to fully meet at times with this staffing level. Sennen Lodge DS0000067982.V328822.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 and 42. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home is run by a manager who needs to exert a more detailed management oversight of the day-to-day operation of the home so that service users are protected and their needs met. EVIDENCE: The owning company has a comprehensive generic set of policies and procedures and a sample of these was inspected. This included policies relating to Adult Protection, Risk Taking, Equal Opportunities, and Racial Harassment. Staff spoken with were aware of the Policies Manual and had access to this when they needed guidance. Sennen Lodge DS0000067982.V328822.R01.S.doc Version 5.2 Page 21 There was evidence however that some day to day practices were not receiving adequate management oversight. For example, the inspector noted in one service user’s file a photocopy of an accident report form dated 3/12/06. The stubs on the accident book itself noted two accidents as having taken place on this day. Neither entry had been completed properly meaning that it was not possible to tell which senior member of staff had had responsibility at the time. There was also a duplication of allocated page numbers for accidents occurring on the 3/12/06 and 2/01/07. The inspector was told that the first two recordings made in the book referred to people living in one of the owning company’s other properties and it was presumed that the book was moved from there. The inspector examined that home’s communication book and noted an entry made by the manager dated 12/01/07 which stated ‘Please note: Prone restraint should not be used within Sennen Lodge. Thank you’. When spoken with about this staff said that this instruction contradicted information contained in care plans. It was reported that this had led to some inconsistency in approach amongst the staff group which potentially posed a risk to service users, and which had not been addressed by senior staff. Staff spoken with at the home were anxious to want to provide a good level of service but felt that they were not as well supported in doing so by the manager as they might be. Sennen Lodge DS0000067982.V328822.R01.S.doc Version 5.2 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 2 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 1 34 1 35 1 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 X 1 X 2 X 1 1 X Sennen Lodge DS0000067982.V328822.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? N/A 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 YA2 Regulation 14(1)(d) Requirement The registered person must ensure that any potential new service user is adequately assessed. The registered person must ensure that assessments are kept under review. The registered person must ensure that all service users are enabled to engage in community activities. The registered person must ensure that medication records are available for inspection. The registered person must ensure that all staff are trained in adult protection. The registered person must ensure that staffing levels are sufficient to meet service users’ assessed needs. The registered person must ensure that all staff files are available for inspection on the premises at all times. The registered person must ensure that accident records are fully completed. Timescale for action 30/04/07 2. 3. YA2 YA13 14(2)(a) 16(2)(m) 30/04/07 30/04/07 4. 5. 6. YA20 YA23 YA33 17(1)(a) Schedule 3 3(i) 13(6) 18(1)(a) 30/04/07 30/04/07 30/04/07 7. YA41 17(3)(b) 30/04/07 8. YA42 17(1)(a) Schedule 3 3(j) 30/04/07 Sennen Lodge DS0000067982.V328822.R01.S.doc Version 5.2 Page 24 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.V328822.R01.S.doc Version 5.2 Page 25 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.V328822.R01.S.doc Version 5.2 Page 26 - 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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