Inspection on 01/12/05 for Shepherds Lodge

This inspection was carried out on 1st December 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 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

Shepherds Lodge 23/01/08

Shepherds Lodge 19/02/07

Shepherds Lodge 02/02/06

Shepherds Lodge 24/11/04

Shepherds Lodge 19/07/04

Shepherds Lodge 18/03/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 Shepherds Lodge 4 West Mount Barrow-in-Furness Cumbria LA14 5LQ Lead Inspector Ray Mowat Unannounced Inspection 01 December 2005 1.00pm Shepherds Lodge DS0000022629.V259072.R01.S.doc Version 5.0 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 Shepherds Lodge DS0000022629.V259072.R01.S.doc Version 5.0 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. Shepherds Lodge DS0000022629.V259072.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Shepherds Lodge Address 4 West Mount Barrow-in-Furness Cumbria LA14 5LQ 01229 431439 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 Adrienne Beattie Mrs Adrienne Beattie Care Home 5 Category(ies) of Learning disability (3), Mental disorder, registration, with number excluding learning disability or dementia (2) of places Shepherds Lodge DS0000022629.V259072.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 5 service users to include: Up to 3 service users in the category LD (Learning Disability) Up to 2 service users in the category MD (Mental Disorder) 24th November 2004 Date of last inspection Brief Description of the Service: Shepherd’s Lodge is a large end of terrace house, situated at the end of a quiet cul de sac in a residential area of Barrow-in-Furness. It is registered to provide residential care for a maximum of six people, with up to two people with a mental disorder and four people with a learning disability. The house is located near to a bus route and is within walking distance of the amenities of the town centre and the railway station. On the ground floor of the house there are two lounges and a conservatory, a kitchen/dining room, a separate kitchen and two bedrooms. One is a resident’s bedroom, the other being a staff sleep-in room and office. There are also laundry facilities outside the home at the rear of the property. There are wellmaintained gardens to the front and rear of the home. There are five resident’s bedrooms on the first floor and two bathrooms with toilets and shower facilities. Shepherds Lodge DS0000022629.V259072.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place at 1pm on 1st December 2005. During the course of the inspection I met with all the current residents, the manager and two care staff that were on duty. I also examined information held by the home relating to each of the residents and records required for the smooth running of the home. What the service does well: What has improved since the last inspection? What they could do better: The home must ensure the medication records are accurate and checked on a regular basis. The contract of terms and conditions should be reviewed to make sure it has all the right information. Confidential information should be securely stored at all times. The home should look at different ways of getting feedback from residents about the quality of the service. The front path should be replaced or repaired as soon as possible as it is getting worn. Shepherds Lodge DS0000022629.V259072.R01.S.doc Version 5.0 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. Shepherds Lodge DS0000022629.V259072.R01.S.doc Version 5.0 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 Shepherds Lodge DS0000022629.V259072.R01.S.doc Version 5.0 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): 1, 2, 3, 4, 5. The home has a robust admissions procedure that allows prospective residents, to make an informed choice about moving into the home. The contracts of terms and conditions need to be reviewed. EVIDENCE: The home currently has two vacancies. A prospective new resident has been visiting the home recently. This has involved a series of overnight stays, which have gradually increased to long weekends. This type of phased introduction to the home is good practice and allows the new resident and existing residents, time to adjust and make an informed choice about the move. During this process the manager has worked closely with the new resident, their family, the social worker and other health professionals to complete a full assessment. This then provides the home with the relevant information to decide if it is able and has the resources to meet their needs. However despite the success of this planned procedure, the move has now been put on hold due to issues relating to funding the placement. This is proving very frustrating, both for the new resident and the home and could jeopardise the placement. Since the last inspection the home had developed a new contract of terms and conditions, however it is recommended this be reviewed to ensure it is in line Shepherds Lodge DS0000022629.V259072.R01.S.doc Version 5.0 Page 9 with all aspects of the National Minimum Standards and Care Home Regulations. Shepherds Lodge DS0000022629.V259072.R01.S.doc Version 5.0 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 the following standard(s): 6, 7, 8, 9, 10. The home is developing good systems to record and respond to individual needs and promote independence. EVIDENCE: Since the last inspection the home has made good progress in developing more detailed care plans and risk assessments. The care plans record people’s needs, strengths and actions required. They also contain informative pen pictures, social histories, daily routines and other personal information. Some of the staff have attended person centred planning training and are now introducing person centred plans into the home. Although in its early stages, the plans are making a difference and ensure the focus is on people’s needs and desires. The risk assessments, whilst maintaining people’s safety are also supporting and promoting people’s independence. In addition to the homes own assessments social work assessments are held on file and kept under review. Within the care plans multi disciplinary strategies have been developed, which guide and support good care practice when dealing with specific behaviours. These have been developed with input from psychologists, the behaviour team and the community nurse, who is working closely with the home on an ongoing Shepherds Lodge DS0000022629.V259072.R01.S.doc Version 5.0 Page 11 basis. This involves staff completing monitoring forms such as behaviour charts, which are periodically reviewed and actions agreed. The home was in the process of completing a new document that records people’s wishes upon their death. This has been produced in pictorial format, which makes it accessible to people with limited literacy skills. It records pertinent information such as religion, the type of service preferred, music and other relevant details particular to the individual and their families. Shepherds Lodge DS0000022629.V259072.R01.S.doc Version 5.0 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 the following standard(s): 11, 12, 13, 14, 15, 16. The home is providing appropriate support, to enable people to enjoy a good quality of life, based on their needs and preferences. EVIDENCE: All the current residents attend some form of day service or work placement on either a full or part time basis between Monday and Friday. This sometimes involves people attending the local college of further education. The home liaises with the day services and work placements, to ensure a continuity of care and promote people’s independence. Three of the residents are able to access community facilities independently for planned activities taking place in known destinations. Risk assessments have been developed to support these activities with the staff monitoring the outcomes and supporting residents with any problems as they arise. One resident recently attended an interview at the job centre independently as a result of the home and their family working together. Residents also enjoy other community activities independently such as visiting the pub, library, the gym and watching local sport events and matches. Shepherds Lodge DS0000022629.V259072.R01.S.doc Version 5.0 Page 13 On the evening of the inspection two residents were going out to a Christmas party, which they were obviously looking forward to. Another resident was planning a Christmas holiday, with support from the manager. This involved them catching a train and meeting up with a friend at a hotel. The home actively encourages and supports residents to keep in touch with family and friends. Based on discussions with residents they have visitors to the home as well as going to visit friends and family. One resident in particular meets their relative two to three times a week. Shepherds Lodge DS0000022629.V259072.R01.S.doc Version 5.0 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 the following standard(s): 18, 19, 20, 21. Personal and healthcare needs were well documented, which ensures a consistent and personalised service is provided. EVIDENCE: Since the last inspection the home has completed health action plans for all the residents. This is a booklet that the local health authority has introduced. It is produced in pictorial format and is used to record all health related activity and appointments. It is the property of the resident, with staff helping them to keep it updated and that they take it to appointments. As mentioned previously the community nurse is working closely with the home, on an ongoing basis, to monitor agreed strategies and support residents and staff. Care plans document people’s daily routines and personal care needs, which ensure a consistent approach from staff, taking note of what is important to individuals. The contents of the medication cabinet were checked against the medical records. The monitored dosage systems were in order, however there was a discrepancy between the PRN medication record and the actual number of tablets. This is subject to a requirement regarding checking medication on a regular basis. Shepherds Lodge DS0000022629.V259072.R01.S.doc Version 5.0 Page 15 The completion of the new information sheets, relating to people’s wishes upon death, will be invaluable in providing appropriate support and respecting person’s wishes. Shepherds Lodge DS0000022629.V259072.R01.S.doc Version 5.0 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 the following standard(s): The policies and procedures of the home and the practice observed, ensure residents concerns are listened to and acted upon and they are safeguarded. EVIDENCE: There have been no recorded complaints since the last inspection. The home has an appropriate policy and procedure in place, which was issued to residents. Staff receive appropriate training with regards to recognising and responding to abuse. The home has a copy of and is aware of the local reporting procedures. The home maintains personal monies books for all the residents to support them in managing their personal allowances. In the absence of a suitable alternative the manager is the signatory on one persons building society account, which is used to pay a bill and draw their personal allowance. All transactions were recorded and receipts retained. The solicitor who represents this resident recently audited this. Shepherds Lodge DS0000022629.V259072.R01.S.doc Version 5.0 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 the following standard(s): On the whole the home provides a comfortable and homely environment, where residents feel safe and their needs can be met. EVIDENCE: The home has completed some planned redecoration and refurbishment, which are to a high standard and improve the living environment. There has been a minor variation approved, which required minor building work to enable the home to create a sixth bedroom and increase the communal space in the home. The fire officer visited the home and approved the alterations. In addition to the main kitchen a kitchen/dining room has been created, which helps to promote independence in relation to preparing snacks and drinks. Resident’s rooms are spacious with each person creating “their own space”, with furniture and fittings to their own taste and interests. As one resident put it “ we have got everything we need”. Overall the home is decorated and furnished to a high standard, with all areas found to be clean and hygienic. Residents take responsibility, with staff support, for cleaning their own rooms. At present there is no need for aids and adaptations in the home. The condition of the front path was discussed with the manager, who explained that it was due to be replaced in the spring 2006. Although it is not causing a Shepherds Lodge DS0000022629.V259072.R01.S.doc Version 5.0 Page 18 hazard at the moment it is deteriorating and will need attention. It is recommended the path is repaired or replaced at the earliest opportunity. Shepherds Lodge DS0000022629.V259072.R01.S.doc Version 5.0 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 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): 31, 32, 33, 34, 35, 36. The home has a well-trained and experienced staff team, who work well together, to meet the needs of residents. EVIDENCE: Based on discussions with residents and staff and by examining the relevant records, it is evident the home provides adequate numbers of staff. This involves the manager working “on shift”, in addition to her management duties. This gives her a good insight to the needs of residents and staff on an ongoing basis. She also provides staff with formal supervision on a regular basis, where they can discuss any issues relating to their role and their development. Staff described the support as “excellent”. Staff felt the recruitment process was both “thorough and fair”. They said they had received good induction and foundation training, which is in line with current good practice and requirements. They also said they received other suitable training, including working towards their NVQ. Staff were clear about their role and responsibilities and had been issued with job descriptions and contracts of employment. CRB disclosures were in place for all staff. With the agreement of the individuals, the manager had identified people to take on specific responsibilities for some aspect of the home or training subject. I spoke to one staff member who was taking a lead role on health Shepherds Lodge DS0000022629.V259072.R01.S.doc Version 5.0 Page 20 and safety. Relevant training was being identified and the manager was supporting them to develop their plans, which is good practice. Shepherds Lodge DS0000022629.V259072.R01.S.doc Version 5.0 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 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, 39, 40, 41, 42, 43. There is a high level of commitment from the manager and staff that ensures the home is run in the best interests of the residents. EVIDENCE: The manager and staff ensure a consistent and reliable service is provided. The manager has a very “hands on” approach and works closely with the care staff to support and encourage good practice. They are clear about their goals and are a committed team, who take a genuine interest in the welfare of the residents. Regular staff and resident meetings are held to share information and discuss any issues of concern. The minutes of meetings reflected an open agenda, with actions identified in response to issues raised. The manager has undertaken a formal quality assurance consultation earlier in the year using a questionnaire, which she did not feel was effective in gaining the views and opinions of residents. It is recommended the home evaluate this process and look at alternatives for getting meaningful feedback on the quality of the service. Shepherds Lodge DS0000022629.V259072.R01.S.doc Version 5.0 Page 22 The home is maintaining appropriate records in line with the National Minimum Standards, however not all confidential information was securely stored. It is recommended the home review its storage, to ensure confidential and personal information is securely stored in line with data protection guidelines. The home had completed a review of their policies and procedures, which were now signed and dated. Other records required fro the running of the home were examined and found to be up to date and in order. The accounts for the previous year confirmed the home was viable. Shepherds Lodge DS0000022629.V259072.R01.S.doc Version 5.0 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 2 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 2 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Shepherds Lodge Score 3 3 2 3 Standard No 37 38 39 40 41 42 43 Score 3 3 2 3 2 3 3 DS0000022629.V259072.R01.S.doc Version 5.0 Page 24 No 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 YA20 Regulation 13(2) Requirement The home must ensure the safe management and storage of medication at all times. Timescale for action 08/12/05 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 2 3 Refer to Standard YA5 YA24 YA39 Good Practice Recommendations It is recommended the contract of terms and conditions be reviewed, to ensure it is in line with all aspects of the National Minimum Standards and Care Home Regulations. It is recommended the front path is repaired or replaced at the earliest opportunity. It is recommended the home evaluate the quality assurance process and look at alternatives for getting meaningful feedback, on the quality of the service and future developments. It is recommended the home review its storage, to ensure confidential and personal information, is securely stored in line with data protection guidelines. 4 YA41 Shepherds Lodge DS0000022629.V259072.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith Cumbria CA11 9BP 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 DS0000022629.V259072.R01.S.doc Version 5.0 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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