Inspection on 13/02/06 for Shepherd`s Lodge

This inspection was carried out on 13th February 2006.

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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Shepherd`s Lodge 13/03/07

Shepherd`s Lodge 01/06/05

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 Shepherd`s Lodge 66 Sheepcot Lane Watford Hertfordshire WD25 ODG Lead Inspector Jeffrey Orange Unannounced Inspection 13th February 2006 07:50 Shepherd`s Lodge DS0000019522.V277823.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Shepherd`s Lodge DS0000019522.V277823.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Shepherd`s Lodge DS0000019522.V277823.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Shepherd`s Lodge Address 66 Sheepcot Lane Watford Hertfordshire WD25 ODG 01923 354 105 01923 465 647 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) Mrs Chan Wan Fong Mr T-Chan Wan Fong Mrs Chan Wan Fong Care Home 3 Category(ies) of Learning disability (3), Mental disorder, registration, with number excluding learning disability or dementia (3) of places Shepherd`s Lodge DS0000019522.V277823.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: There are none Date of last inspection 1st June 2005 Brief Description of the Service: Shepherds 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 Watford Shelter Work Shop. Another service user has changed employment from dinner supervision at Oakland College to the Watford Shelter Work Shop. Shepherd`s Lodge DS0000019522.V277823.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection began early in the morning, which gave an opportunity to meet with service users and staff as they went about the routine of getting up, having breakfast and getting ready for the day’s activities. The inspector would like to thank service users and staff for enabling the inspection to proceed, hopefully without causing any avoidable disruption to the home’s routine or to residents and staff. During this visit it was also possible to look at some key records, like medication, recruitment,care plans and finances. Useful discussions about individual service users, records and social care regulation were held with the proprietor/ manager. This was another very positive inspection. A good standard of care was observed and the standard of record keeping remains good as well. The majority of the key standards were assessed during the previous inspection of the 1st June 2005. Where that is the case they have not necessarily been re-assessed on this occasion and therefore, for full details, reference should be made to the report of that inspection. What the service does well: What has improved since the last inspection? What they could do better: Some relatively minor improvements to medication storage and practice are required, however the overall standard of medication practice remains good. Any restrictions placed on service users movement must be recorded in a risk assessment with the rationale behind the movement clearly recorded. This is a matter of recording practice and does not indicate inappropriate restrictions are in place. Shepherd`s Lodge DS0000019522.V277823.R01.S.doc Version 5.1 Page 6 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. Shepherd`s Lodge DS0000019522.V277823.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Shepherd`s Lodge DS0000019522.V277823.R01.S.doc Version 5.1 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 the following standard(s): These key standards were assessed during the inspection of the 1st June 2005, for full details please see the report of that inspection. EVIDENCE: Shepherd`s Lodge DS0000019522.V277823.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6&9 The high standard of care planning means that service users needs are subject to a robust system of assessment and review. Care is then provided and adjusted in line with those reviews within a robust risk assessment framework that offers support and protection to the home’s service users. 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 in respect of service users were seen during this inspection. All service users are supported within the Care Programme Approach framework to ensure changing needs are continuously assessed and reviewed. Shepherd`s Lodge DS0000019522.V277823.R01.S.doc Version 5.1 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 & 16 Service users are able to take part in a range of leisure activities. Records in respect of restrictions placed upon service users should be made more explicit. It is acknowledged that the home works closely in this regard with a range of specialist professionals and that restrictions currently in operation are in accordance with assessed risks and/or requirements placed upon the home under the Mental Health Act. EVIDENCE: Care plans, discussions with service users and the manager provide evidence of the use of a range of community facilities such as libraries and gyms. One service user had to ask for the front door to be unlocked to enable him to leave for his days’ activities. This practice is not specifically recorded although it is clearly in line with the requirements of his placement and risk assessment. Shepherd`s Lodge DS0000019522.V277823.R01.S.doc Version 5.1 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 The standard of medication practice is good. Medication storage temperatures should be monitored and recorded and the date of opening of medication not supplied in blister packs or similar should routinely be recorded. These improvements will ensure that medication is stored at the appropriate temperature and is used within the recommended time-span. EVIDENCE: Medication records were checked and found to be correct. There is no procedure in place to monitor the storage temperature of medication in the home. Medication that is not supplied to the home in blister packs, had not been marked with the date upon which it was opened. This means that it is not possible to either accurately monitor storage temperatures to make sure they are within recommended ranges that ensures they remain effective or to ensure that all medication is used within the recommended time-span once opened. Shepherd`s Lodge DS0000019522.V277823.R01.S.doc Version 5.1 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These key standards were assessed during the inspection of the 1st June 2005, for full details please see the report of that inspection. EVIDENCE: Shepherd`s Lodge DS0000019522.V277823.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These key standards were assessed during the inspection of the 1st June 2005, for full details please see the report of that inspection. EVIDENCE: Shepherd`s Lodge DS0000019522.V277823.R01.S.doc Version 5.1 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34 The home operates a robust recruitment process which should provide confidence and protection to service users. EVIDENCE: The recruitment file for a recently employed member of staff was inspected and found to contain all the required information. Shepherd`s Lodge DS0000019522.V277823.R01.S.doc Version 5.1 Page 15 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 38 40 & 43 The home is organised and managed in a way that puts the service users at the centre of decision- making and makes their care and safety the principal focus of the home’s procedures. This reality needs to be fully supported by the home’s risk assessment records in each case. There is one requirement made in respect of a specific need to explicitly record every occasion when a restriction upon service users freedom is in place, however justified, reasonable and realistic that may be. To avoid any doubt, this is a matter of recording practice and does not suggest that any inappropriate restrictions are currently in place. EVIDENCE: The management of the home is effective in ensuring that changing needs of service users are assessed and met and that the home is meeting its expressed aims and objectives. The overall standard of record keeping is very good. A sample record of financial transactions made on behalf of service users was found to be in order with a robust system of checks and balances in place. Shepherd`s Lodge DS0000019522.V277823.R01.S.doc Version 5.1 Page 16 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 X 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 X 23 X ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 X 34 3 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X 3 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 3 15 X 16 2 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 X 3 3 X 2 X X 3 Shepherd`s Lodge DS0000019522.V277823.R01.S.doc Version 5.1 Page 17 There were none. 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 YA16 Regulation 13(7&8) Requirement Any restrictions on the freedom of movement of service users must be explicitly recorded and linked to a risk assessment. The storage temperature for medication held in the home must be monitored and recorded to ensure it remains within recommended levels. The date of opening must be recorded where medication is supplied to the home other than in blister packs or monitored dosage systems. Timescale for action 30/06/06 2 YA20 13(2) 13/02/06 3 YA20 13(2) 13/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Shepherd`s Lodge DS0000019522.V277823.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire 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 Shepherd`s Lodge DS0000019522.V277823.R01.S.doc Version 5.1 Page 19 - 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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