Inspection on 01/06/05 for Shepherd`s Lodge

This inspection was carried out on 1st June 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Shepherd`s Lodge 13/03/07

Shepherd`s Lodge 13/02/06

Shepherd`s Lodge 18/03/05

Shepherd`s Lodge 07/06/04

Similar services:

Claremont House

Oak Ridge

Coopers Mill Ltd

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Paradise Lodge

Bilney Hall

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

CARE HOME ADULTS 18-65 Shepherds Lodge 66 Sheepcot Lane Watford Hertfordshire WD25 0DG Lead Inspector Julia Bradshaw Unannounced 01.06.05 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 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 Stationary 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. Shepherds Lodge I52_s19522 Shepherds Lodge v228249 010605 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Shepherds Lodge Address 66 Sheepcot Lane Watford Hertfordshire WD25 0DG 01923 354105 01923 465647 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Chan Wan Fong Mrs Chan Wan Fong Care Home 3 Category(ies) of LD LD Learning disability - 3 registration, with number MD MD Mental Disorder - 3 of places Shepherds Lodge I52_s19522 Shepherds Lodge v228249 010605 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: There are none. Date of last inspection 18.03.05 Brief Description of the Service: Shepherd’s Lodge is a detached bungalow in a residential road in Garston. Public transport, local shops and leisure facilities are all reasonably close by. The home accommodates three service users with learning disabilities. There are three single bedrooms, a lounge/dining room, kitchen and bathroom/wc. The home has a large garden, which the proprietors are in the process of redesigning. It contains a large pond with a decorative footbridge over it, and a summerhouse. One service user has successfully completed his community access and I.T. courses at Cassio College. He is presently working at the Watfrod Shelter Work Shop. Another service user has changed employment from dinner surpervision at Oalkand College to the Watfrod Shelter Work Shop. Shepherds Lodge I52_s19522 Shepherds Lodge v228249 010605 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first unannounced inspection of the inspection year and took place over one day. The majority of time was spent talking to the manager, member of staff on duty and the service user who was at home. Some time was also spent looking at Service user Plans, risk assessments, complaints, staff training, and staff files. Discussions were held with the manager Mrs Chan Wan Fong regarding the new inspection format and report. Service users and staff were very welcoming This was a very positive inspection, and all the standards inspected were met. What the service does well: What has improved since the last inspection? There is very little that the home needed to implement from the last inspection as there were no requirements or recommendations. Shepherds Lodge I52_s19522 Shepherds Lodge v228249 010605 stage 4.doc Version 1.30 Page 6 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. Shepherds Lodge I52_s19522 Shepherds Lodge v228249 010605 stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Shepherds Lodge I52_s19522 Shepherds Lodge v228249 010605 stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4,5. The home carries out a comprehensive and detailed system of assessment for all service users. The service users and staff create a welcoming and inclusive atmosphere. Information provided to the service user about the home and its terms is accurate and detailed. Documentation seen was appropriate and presented in a format for service user to make an informed choice about where to live. EVIDENCE: A comprehensive Statement of Purpose and Service User Guide is available and prospective service users are provided with a copy. Pre-admission assessments had been carried out prior to admission and the manager reviews these assessments as part of the Care Planning Approach programme. A care plan summary is available. Each service user signs their service user plan as part of the overall assessment process. Qualified and competent people complete the assessments. The home also receives and seeks external specialist support to meet the individual service users needs. Care programme reviews occur within the home to support the service users in achieving and reviewing individual needs, goals and aspirations. Shepherds Lodge I52_s19522 Shepherds Lodge v228249 010605 stage 4.doc Version 1.30 Page 9 The admissions procedure to the home includes trial visits for the service users to make an informed choice about where to live. A contract is then drawn between the home and the service user. The contract includes the terms and conditions within the home and the rights of the service user. The admissions policy is to be forwarded to the Commission for Social Care Inspection. Shepherds Lodge I52_s19522 Shepherds Lodge v228249 010605 stage 4.doc Version 1.30 Page 10 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 standard(s) 6,7,8,9,10. Individual needs and choices within the home are being promoted to encourage and empower user self-determination. Service user plans fully reflect the service users needs. Service users have the opportunity to contribute to decisions taken within the home. Service users risk assessments are in place and reflect risks in relation to personal health and safety. EVIDENCE: All service users have an individual care plan and an allocated key worker to support them within the home. Individual daily notes and guidelines for the service users where observed within the home. All service users are supported within the Care Programme Approach framework to ensure changing needs are continuously assessed and reviewed. The ethos within the home promotes that the care plans of each individual are owned by the individual, those service users spoken to during the inspection were aware of their individual care plans. Shepherds Lodge I52_s19522 Shepherds Lodge v228249 010605 stage 4.doc Version 1.30 Page 11 Within the home each service user is encouraged to partake in some daily living tasks. All information within the home is handled with care and respect. All personal notes and files detailing information on the service user are locked away. The home has excellent risk assessment procedures and all risk assessments were up to date and accurate regarding generic risk assessments. There were also some individual risk assessments in place, in particular, with regard to one service user who has a history of absconding form the home and who requires clear and detailed guidelines regarding the management of personal monies. The home has good systems of communication with both the service users and their carers and information is made available. There is a general policy on confidentiality. Service users’ individual records are accurate and they are stored securely in a locked filing cabinet. All staff signs each document to confirm they have read the necessary policies and procedures. Shepherds Lodge I52_s19522 Shepherds Lodge v228249 010605 stage 4.doc Version 1.30 Page 12 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 standard(s) 11,12,13,15,17. Personal development opportunities are encouraged for all service users ensuring interactions with the outside community are encouraged. Individual rights and opportunities are recognised and supported, where possible. Restrictions on service users independence and rights are recognised and respected. Personal and sexual relationships are supported in a mature and professional manner. Service users are provided with a varied and wholesome diet. EVIDENCE: Shepherds Lodge I52_s19522 Shepherds Lodge v228249 010605 stage 4.doc Version 1.30 Page 13 Two out of the three service users living at Shepherds lodge attend the Sheltered Workshop within Watford Town Centre. This is a full time placement and service users attend from 9a.m. to 4.30p.m. The third service user chooses to remain at home during the day and therefore the manager/proprietor and staff provide an alternative day care programme for him. The manager has worked hard to endeavour to provide alternative day care opportunities to this person although the service user has chosen not taken these up. One service user is able to go out independently. The home provides a range of social and leisure activities for all three-service users; these include The “Magpie” club, the Jubilee Club, bowling trips, regular trips to the cinema, golf, shopping trips to Brent Cross and Watford. The home is in the process of also co-ordinating holidays and have several trips planned for later on in the year including, a weeks holiday in Bournemouth, a trip to Worthing in July and to Portsmouth in August. The service users are also taking a trip on the London Eye later this month and a trip to the London Aquarium in September. Service uses are unrestricted in their movement around the home, with the exception of the kitchen area where staff support is required. The home should be congratulated on providing a varied and wholesome menu and diet. There was evidence to support that service users are fully involved in choosing their own meals and take turns to assist in the weekly shopping trips. The home has regular advice and support form the local community dietician. Alternatives are recorded, when required, although this is rare as the home has detailed knowledge of all the service users likes and dislikes and therefore provides the appropriate meals accordingly. Shepherds Lodge I52_s19522 Shepherds Lodge v228249 010605 stage 4.doc Version 1.30 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19,20. The current medication practices and maintenance for medication are detailed and comprehensive. The ageing, illness and death of a service user is handled with respect and information recorded is accurate. Service users emotional and physical needs are being met adequately. EVIDENCE: The current service users are all independent in personal care, but support is provided when needed in their rooms. The manager and staff are all female, but the joint proprietor/deputy manager is male, and he is in the home every day. Service users can choose when they get up and go to bed, and they choose and pay for their own clothes and haircuts. For those who are assessed, mental health needs are met by visiting community psychiatric nurses and social workers. Service users visit their psychiatrists on an out patient basis. All the service users are registered with the same GP practice, but with different GPs. They visit a local dentist, optician and chiropodist when required. Shepherds Lodge I52_s19522 Shepherds Lodge v228249 010605 stage 4.doc Version 1.30 Page 15 The home currently uses a monitored dosage system for dispensing medication. One of the current service users administers their own hay fever medication and an up to date risk assessment in relation to this medication is in place. The home’s medication was suitably stored and the disposals book was up to date. All new staff receives a full induction, which includes three observation sessions with a senior member of staff before they are able to administer medication and assessed as competent. The manager has worked hard to establish each service users last wishes and funeral arrangements and these are recorded as part of the service user plan. Shepherds Lodge I52_s19522 Shepherds Lodge v228249 010605 stage 4.doc Version 1.30 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) The complaints procedure within the home is sufficient and adequate in order for the service users to feel that their individual views are listened to. Robust policies, procedures and training are in place to ensure service users are protected and safe. EVIDENCE: The home has a comprehensive complaints procedure in place, which details that the manager responds to all complaints. A record is maintained within the home of complaints made detailing actions and outcomes as necessary. The home has received no complaints since the last inspection. All service users have been informed about the complaints procedure. This is also on display within the home. The complaints procedure includes the correct contact details of the CSCI. Robust procedures are in place to ensure that service users are protected from abuse and harm. Staff receive adequate Protection of Vulnerable Adults (POVA) training, which was last held in 2004. Staff employed within the home are all subject to enhanced Criminal Records Bureau (CRB). Staff personnel files were inspected and contained all the required information. Shepherds Lodge I52_s19522 Shepherds Lodge v228249 010605 stage 4.doc Version 1.30 Page 17 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 standard(s) 24,25,26,27,28,30. The home and its surroundings offer a pleasant, comfortable and safe environment to its service users. The home is extremely clean and well maintained. All bedrooms are personalised offering a homely, lived in feel. EVIDENCE: Service users are encouraged to bring personal items such as furniture and pictures into their room when they move in. Service users spoken to were happy with their rooms and commented on how staff assist them in choosing and purchasing new items for their rooms and are wholly involved in deciding on their own colour schemes and soft furnishings. The home is exceptionally clean and attention to detail is given. The cleaning of the home is carried out by the care staff and with service users assisting where possible. The manager monitors this closely to ensure that standards of cleanliness remain high. Hygiene and infection controls are high. The kitchen/ laundry area are domestic in style and appear to manage their current workload effectively. The home has one domestic style bathroom with a bath/shower and toilet. Water temperatures were checked and were being delivered within safe limits. Shepherds Lodge I52_s19522 Shepherds Lodge v228249 010605 stage 4.doc Version 1.30 Page 18 The home provides sufficient lighting, heating and ventilation. A maintenance and renewal and redecoration plan is required. Each service user has a single bedroom. The communal areas of the home are decorated and furnished to a high standard and there is a range of home entertainment equipment for service user to access. The home also benefits from having an enclosed garden area and a large Gazebo with a Koi carp pond, for service users to enjoy. There is a large brick built shed at the rear of the garden, which is used for storage. The home has a side gate fitted to the property, in order to increase security to the home. Shepherds Lodge I52_s19522 Shepherds Lodge v228249 010605 stage 4.doc Version 1.30 Page 19 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,33,35,36. The home is suitably staffed with well-trained and experienced individuals ensuring that at all times service users changing needs can be met. The staff team are enthusiastic and appear to take great pride in the service. Recruitment procedures are robust and effective in the protection of service users. The manager is providing an effective programme of training. EVIDENCE: The Staff spoken with during the inspection appeared to be clear of their individual roles and responsibilities. The member of staff on duty was seen to support the main aims and values of the home. The home has clearly defined job descriptions and person specifications in place. All staff have received a series of mandatory training course in order for them to meet the needs of the service users. Recent training includes, food and nutrition, first aid and mental health training, challenging behavoir, loss and bereavement and fire training. Accurate training records are maintained within the home. Shepherds Lodge I52_s19522 Shepherds Lodge v228249 010605 stage 4.doc Version 1.30 Page 20 Recruitment practices were inspected and proven to be accurate and the two files checked contained all the required information. Supervision and appraisal occur within the home. The home employs three full time staff who work both day and night shifts, and are also in the process of recruiting one further member of staff to cover a part-time post. Shepherds Lodge I52_s19522 Shepherds Lodge v228249 010605 stage 4.doc Version 1.30 Page 21 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39,41,42 The management within the home is secure and effective ensuring that changing needs of service users are met and that the home is running meeting its aims and objectives. Quality assurance systems are in place . All service user meetings need to be documented. Health and safety standards within the home are excellent. EVIDENCE: Service users appear to be extremely happy with the home and observed to be relaxed in their environment. The relationship between the service users and the staff is well balanced with interactions observed being appropriate and supportive. The ethos and management approach of the home creates an open, positive and inclusive atmosphere, staff and the service user spoken to Shepherds Lodge I52_s19522 Shepherds Lodge v228249 010605 stage 4.doc Version 1.30 Page 22 commented that they feel supported and valued and that they feel the home is well managed. A clear commitment is made to equal opportunities within the home, with staff and service users expressing positive views with regards to this. The service users appeared to benefit from this well structured and well run home. The staff and manager within the home are adequately and suitably trained in order to meet the complex changing needs of the service users. Quality assurance systems are in place and the home conducts an annual audit. The manager has daily contact with each service user and therefore the service users have the opportunity to raise issues or concerns informally. The service users spoken to felt that their views were listened to and considered. All records are secure within the home and were up to date and held in accordance with the Data Protection act 1998 ensuring that service users rights and best interests are safe guarded by the homes polices and procedures. Records regarding staff recruitment were inspected and there was adequate evidence to confirm that the recruitment and selection procedures were being adhered to. Individual and generic risk assessments were in place within home, with all external required safety checks occurring. All fire records were up to date and all health and safety records were in place and being maintained appropriately. Shepherds Lodge I52_s19522 Shepherds Lodge v228249 010605 stage 4.doc Version 1.30 Page 23 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 x 3 Standard No 11 12 13 14 15 16 17 3 3 3 x 3 x 3 Standard No 31 32 33 34 35 36 Score 3 x 3 x 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Shepherds Lodge Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x x 3 x 3 3 x I52_s19522 Shepherds Lodge v228249 010605 stage 4.doc Version 1.30 Page 24 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard Regulation Requirement There were no requirements Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations There were no recommendations. Shepherds Lodge I52_s19522 Shepherds Lodge v228249 010605 stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection Mercury House 1 Braodwater Road Welwyn Garden City Herts AL7 3BQ 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 Shepherds Lodge I52_s19522 Shepherds Lodge v228249 010605 stage 4.doc Version 1.30 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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