Inspection on 13/03/07 for Shepherd`s Lodge

This inspection was carried out on 13th March 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Shepherd`s Lodge 13/02/06

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 Julia Bradshaw Unannounced Inspection 13 March 2007 10:00 th Shepherd`s Lodge DS0000019522.V333374.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 Shepherd`s Lodge DS0000019522.V333374.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. Shepherd`s Lodge DS0000019522.V333374.R01.S.doc Version 5.2 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), Old of places age, not falling within any other category (1) Shepherd`s Lodge DS0000019522.V333374.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate one (named) service user who is over the age of 65 for as long as their needs can continue to be met. 13th February 2006 Date of last inspection 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. The fee range for this service is from £980 - £1200 per week. Information regarding the service can be obtained from the Service User Guide and Statement of Purpose. Shepherd`s Lodge DS0000019522.V333374.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was the first inspection for the year 2006/7 and took place over one day At the beginning of the visit there was only one service user at home. However the most recent service user admitted into the home returned whilst the inspection was still taking place. The main focus of the inspection was on checking the progress made in complying with the statutory requirements made at the last inspection in February 2006. Discussions were held with one of the service users present and the registered manager. Documentation examined included the new service users care plan, the service user’s guide, staff recruitment, supervision and training records and quality monitoring records. A tour of the premises was made, taking in all the bedrooms, communal areas and the grounds of the home. The inspection indicated that the home was running well, with a calm atmosphere and reasonably settled service users being cared for by confident, well-trained and highly motivated staff. Requirements have been made in respect of the service user’s autonomy/risk assessment. What the service does well: The home achieves a high standard of support for people with a learning disability/Mental health need. There are various systems in place, which reflect this expertise, and working practices were observed as both professional and appropriate to the needs of the service users. The home has produced excellent service user plans and should be congratulated on the comprehensive and detailed information provided in these documents. The manager works hard to maintain a homely and comfortable atmosphere in which service users clearly respect and appear to appreciate this home. The home has an excellent assessment system in place, which is both detailed and comprehensive in its approach to identifying all the needs of new and existing service users. Detailed information is provided about the operation of the service to prospective and current residents. This small staff team is both committed and enthusiastic in their approach to service users. The service users appear to have some of involvement in their care planning and this has produced a person-centred plan that enables staff to create an individual service in order to meet each service user’s needs and aspirations. Shepherd’s Lodge is a pleasant place to live where service users appear to feel secure and respected and this is reflected in the continuing levels of improvement. Shepherd`s Lodge DS0000019522.V333374.R01.S.doc Version 5.2 Page 6 The bedrooms are well presented and have suitable furnishings and décor that both promote the residents’ dignity and provide an acceptable level of comfort and individuality. 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. Shepherd`s Lodge DS0000019522.V333374.R01.S.doc Version 5.2 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.V333374.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1-5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A Statement of Purpose and a Service User’s Guide is availablethat contains the required information about the service promised. These documents are made available to all prospective and current residents and their representatives and enable them to make an informed decision about whether the home would be suitable. The documents are produced in a format that is accessible to the service users. EVIDENCE: Full assessments are made of every prospective service user’s needs, abilities, personal preferences and aspirations prior to admission so that it is clear that the home will be able to meet the individual’s requirements. The admissions procedure also includes a series of planned trial or familiarisation visits to allow the service user to experience the atmosphere and way of working in the home before making any firm commitment to a ‘permanent’ stay. The Service User’s Guide contains details of the rights and responsibilities of both home and service user as a rough summary of the terms and conditions of residence. It is suggested that a copy of this is left in a prominent position in the reception area. The records and assessment of the most recent admission were inspected and were found to be both detailed and comprehensive. Shepherd`s Lodge DS0000019522.V333374.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): 6-10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ needs and aspirations are detailed in comprehensive individual care plans that provide excellent information to facilitate consistent care. Service users can contribute to some decision making in their personal lives and in the running of the home, supported by staff as necessary. Service users are supported to take responsibly assessed risks that balance health and safety and opportunities for stimulation and independence. Staff follow the home’s policy and maintain confidential information appropriately. EVIDENCE: Shepherd`s Lodge DS0000019522.V333374.R01.S.doc Version 5.2 Page 10 The manager must ensure that autonomy and choice is promoted to all service users. Whilst there are occasions where boundaries have to be implemented, the manager and staff must ensure that service users care plans reflect this. Care plans examined were both detailed and comprehensive containing details of individual needs, personal preferences, goals set, behavioural guidelines, medical care needs. The plans were set out in a clear format, very accessible to the reader (including the service user) and provided invaluable information on the person as a human being and clear instructions to staff on how to proceed to achieve the best outcomes. Staff frequently update the care plans in the light of changing needs. The staff team should be congratulated on the hard work and professionalism that has contributed to producing service user plans that are comprehensive and very detailed. Staff work with residents to assist them to lead safe and enjoyable lives, consulting them as appropriate over decision making and offering guidance where needed. Positive interaction was observed between the manager and residents during the inspection, demonstrating a high level of respect and patience. Up to date risk assessments were in place covering a wide range of activities. There is a policy on confidentiality that staff are aware of and follow. Personal information about service users is handled sensitively and documents are stored securely. Shepherd`s Lodge DS0000019522.V333374.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): 12-17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal development opportunities are encouraged for all service users ensuring interactions with the outside community are encouraged, although this can prove problematic due to the rural location of the home. Individual rights and opportunities are recognised and supported, where possible. Restrictions on service users independence and rights are on occasions compromised. Personal and sexual relationships are supported in a mature and professional manner. Service users are provided with a varied and wholesome diet. Shepherd`s Lodge DS0000019522.V333374.R01.S.doc Version 5.2 Page 12 EVIDENCE: The staff should be congratulated in supporting one service user who has achieved full time employment since the last inspection took place. One service chooses to stay at home and therefore the care staff provides their day care, which includes shopping trips, meals out, visiting the local library and museums. The remaining service user attends a local college for further education. A range of activities outside of the home are provided, which include, day trips to the coast, attending the local gym for fitness and exercise and the home also offers annual holidays. Last year service users went to Butlins for a week with two staff and with all three-service users. The service users have expressed an interest in having a holiday in June, to Blackpool. Service users are actively encouraged to participate in the domestic routines around the home, including weekly shopping trips, assisting with personal washing/drying of clothes, cooking and each week every service user thoroughly cleans their bedrooms. All service users are encouraged and supported to maintain links to the local community. The service users attend local clubs including, the Magpie club, the Jubilee club and the Gateway club in Rickmansworth. One service user is involved in a local Rugby team (Bravehearts) and he enjoys attending matches all over the country. The home should be congratulated for supporting and encouraging this service user in maintaining his interest in this activity. Shepherd`s Lodge DS0000019522.V333374.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): 18-21. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The current medication practices and maintenance for medication are sufficient and adequate. The ageing, illness and death of a service user are handled with respect and information recorded is accurate. Service users emotional and physical needs are being met adequately. EVIDENCE: The current arrangements for the storage and handling of medication are adequate and meet the current standards. The medication cupboard is situated within the main reception area of the home. All staff have been trained and inducted in the administering medication. The manager ensures that all “homely” remedies are authorised for all service users who require them. There is currently no controlled medication held in the medication cupboards, however there is a robust procedure in place for the administration of these medications, if required. Health records are maintained within the main service Shepherd`s Lodge DS0000019522.V333374.R01.S.doc Version 5.2 Page 14 user plan. Files checked confirmed that all three-service users have regular health checks including, dentist, chiropodist (where appropriate) opticians and the CPN visits, when necessary. Medication was checked and all administration and recording of medication was being carried out in line with the home’s medication policy. The liquid medication contained a date of opening. The home now has a thermometer inside the fridge in order to ensure the cupboard is maintained within safe limits and so remains clinically effective. Shepherd`s Lodge DS0000019522.V333374.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): 22-23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints procedure is sufficient and adequate in order for the service users to feel that their individual views are listened too. Robust policies, procedures and training are in place to ensure service users are protected and safe. EVIDENCE: A detailed complaints procedure is in place and is on display. A record is maintained of any complaints made detailing actions and outcomes as necessary. No complaints have been received since the last inspection was carried out. All service users have been informed about the complaints procedure. A detailed procedure is in place to ensure that service users are protected from abuse and harm. Staff receive suitable and adequate Safeguarding Adults training. Staff employed within the home are all subject to enhanced Criminal Records Bureau (CRB). Shepherd`s Lodge DS0000019522.V333374.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): 24-30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a safe and comfortable environment in which to live. Individual bedrooms were personalised which promoted independence and choices and preferences for the service users. The service users health and safety is protected. EVIDENCE: The manager and Proprietor have worked hard to create a comfortable homely environment in which service users can enjoy and relax in. The manager’s husband carries out most of the maintenance and has developed the garden area in the last two years to include a large pond and vegetable patch, in which service users can grow their own selection of vegetables. Shepherd`s Lodge DS0000019522.V333374.R01.S.doc Version 5.2 Page 17 The service users can enjoy a range of in-house entertainments, including a Television/DVD and video, which are located in the lounge. Also service users all have televisions in their bedrooms. The home has one bathroom/shower unit, a large lounge and dining room. The kitchen is domestic in style and has all the necessary appliances. Fridge and freezer temperatures are recorded. Hot water temperatures are maintained within safe limits. The home has a large back garden that service user can enjoy in the warmer months. All areas of the home are maintained to a high standard. The home does need the services of clinical waste disposal service. Shepherd`s Lodge DS0000019522.V333374.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): 31-36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff know and support the aims and values of the home and how their roles contribute to achieving them. Staffing levels are adequate to provide the attention that the service users require and to achieve the aims of the home. Members of staff are enthusiastic, knowledgeable, experienced and well trained to support service users effectively and meet their needs. Sound recruitment practices are oerated that protect the interests of service users. Staff are well supported and receive individual supervision. Shepherd`s Lodge DS0000019522.V333374.R01.S.doc Version 5.2 Page 19 EVIDENCE: Staff are clear of their individual roles and responsibilities. There is a loyal core staff team that appear to have a good understanding of the current service users needs and abilities. The manager was the only person on duty at the time of the inspection, although a further member of staff would be due to come on duty at 3 p.m. Mr and Mrs Chan Wan Fong are joint registered providers. There is one manager and five support staff. These members of staff do both day and night shifts. Staff have 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 complex needs of the service users. Training in Safeguarding Adults is provided as part of a rolling mandatory training. The company has rigorous recruitment procedures that involve thorough vetting of applicants. Two staff files examined contained photographs of the person, application forms, two positive references and CRB disclosures. All new staff receives structured induction and foundation training. The manager maintains excellent records in relation to training. Recent training includes, fire safety, food hygiene and Safeguarding Adults .The manager ensures that all staff have mandatory training provided. There is currently one member of staff who has NVQ level 2. The manager is currently in the process of doing her NVQ level 4. The manager carries staff supervisions out on a regular basis and meets the required standard. Shepherd`s Lodge DS0000019522.V333374.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): 37,39,42,43. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Health and safety of service users, staff and visitors is adequate. Sheperd’s Lodge is well run, with service users benefiting from the support and guidance of the manager and the committed and enthusiastic staff team. The manager has been in post since the home was registered and is experienced and qualified and provides strong leadership to the team. The home is operated in an inclusive manner that enables staff to contribute ideas and the service users to have some control over their lives within a risk assessment framework. Self-monitoring systems are good. Shepherd`s Lodge DS0000019522.V333374.R01.S.doc Version 5.2 Page 21 EVIDENCE: The management approach endeavours to create an open and positive atmosphere, staff and service users spoken to commented that they feel supported and feel the home is well managed. A clear commitment is made to equal opportunities. Adequate training is being provided to ensure all staff have the necessary underpinning knowledge to carry out their role effectively. Supervision sessions are completed in line with the required standards. Quality assurance systems are in place. Service user finances were checked and reconciled. Separate ledgers are maintained for each person and a running record is kept and audited every time a withdrawal is made. Data Protection Act 1998 ensuring that service users rights and best interests are safe guarded by the polices and procedures. Records regarding staff were not inspected and must be held within the home for inspection. There are currently no outstanding issues relating to the health and safety. All fire records were up to date and accurate. The annual insurance certificate was dated November 2007. Shepherd`s Lodge DS0000019522.V333374.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 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 x x x x 3 3 Shepherd`s Lodge DS0000019522.V333374.R01.S.doc Version 5.2 Page 23 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(4) (b) Schedule 1 (10) Requirement The manager must review the current arrangement of locking the front door at all times as this currently compromises service users rights to freedom of movement. A risk assessment should be drawn up and implemented. Timescale for action 14/03/07 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 Shepherd`s Lodge DS0000019522.V333374.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Hertfordshire Area Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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 Shepherd`s Lodge DS0000019522.V333374.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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