Inspection on 02/02/06 for Shepherds Lodge

This inspection was carried out on 2nd February 2006.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also 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 01/12/05

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 2nd February 2006 08:00 Shepherds Lodge DS0000022629.V275671.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 Shepherds Lodge DS0000022629.V275671.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. Shepherds Lodge DS0000022629.V275671.R01.S.doc Version 5.1 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 6 Category(ies) of Learning disability (4), Mental disorder, registration, with number excluding learning disability or dementia (2) of places Shepherds Lodge DS0000022629.V275671.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 6 service users to include: Up to 4 service users in the category LD (Learning Disability under 65 years of age) Up to 2 service users in the category MD (Mental Disorder under 65 years of age) The home must at all times employ a suitably qualified and experienced manager. 1st December 2005 2. 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.V275671.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place at 8am to enable me to see the morning routines of the home. I met with all the residents during the inspection and looked at records relating to their care. I also spent time with the manager and two care staff on duty and looked at records held for the management of the home. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Shepherds Lodge DS0000022629.V275671.R01.S.doc Version 5.1 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Shepherds Lodge DS0000022629.V275671.R01.S.doc Version 5.1 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5. There are good systems in place to ensure a thorough assessment is completed prior to admission this ensures a smooth transition into the home. EVIDENCE: The home currently has one vacancy. The manager described how the most recent resident was introduced to and moved into the home. The manager visited the prospective resident in their home to complete an initial assessment. She also liaised with a social worker and community nurse to obtain an accurate assessment of specialist needs. A series of visits to Shepherd’s Lodge were arranged, so that the prospective resident and the existing residents could meet and they could become more familiar with the home environment. After the visits a three-month trial period was agreed to enable both parties to make an informed choice. The home continues to work closely with the community nurse and health service team to establish strategies and routines to support the new resident. They are also completing a comprehensive personal and social skills assessment to help develop a meaningful care plan. An occupational therapy assessment has also been completed and there has been ongoing support from the district nurse. The home must review their contract of terms and conditions to ensure all aspects of the National Minimum Standards are included. Shepherds Lodge DS0000022629.V275671.R01.S.doc Version 5.1 Page 8 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. Resident’s needs are well-documented enabling staff to provide an individualised service that promotes and supports an independent lifestyle. EVIDENCE: Each resident has a detailed care plan in place, which is kept under review. The care plans have been developed with input from a multi-disciplinary team, providing specific strategies to guide and support staff in responding to specialist needs. Individual communication books are used on a daily basis to record and share pertinent information, such as health appointments and other significant events ensuring a consistent service. Due to the complex needs of one resident the home has been working closely with a number of health professionals to help the home assess and respond to specialist needs. There was evidence there had been good progress made and the transition into the home had been effective. Residents have a lot of autonomy to pursue their chosen lifestyle, with some of them enjoying independence both in the home and in the local community. The district nurse visits one resident on a daily basis. Since their admission they have made a good improvement and the manager is helping to ensure a coordinated approach to their personal and healthcare needs. Shepherds Lodge DS0000022629.V275671.R01.S.doc Version 5.1 Page 9 A good range of personal and general risk assessments have been developed to maintain the safety of residents and staff, whilst promoting an independent lifestyle. Shepherds Lodge DS0000022629.V275671.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): 11, 12, 13, 14, 15, 16, 17. Residents are supported to lead independent lifestyles both in the home and in the community. EVIDENCE: I joined the residents at the breakfast table during which time they talked to me about their daily routines. Four of the five residents attend some form of day service each week, Monday to Friday. This incorporates vocational, educational and leisure activities, which can also include courses at the local College. Staff were encouraging independence, providing verbal prompts to guide residents through their morning routine. Four of the residents are able to access the local community independently, with staff providing moral support and guidance. They use the local shops and amenities on a daily basis, as well as enjoying leisure activities such as visiting the pub for a meal or for a drink with friends, watching local sports events and visiting friends and family. Residents also have frequent visitors to the home. During the inspection staff from another agency came into the home to work on a one to one basis with a resident. The resident was aware this was taking Shepherds Lodge DS0000022629.V275671.R01.S.doc Version 5.1 Page 11 place and had talked to me about what she planned to do, “bake some cakes”, which she did. Shepherds Lodge DS0000022629.V275671.R01.S.doc Version 5.1 Page 12 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. The home works proactively with a number of agencies to ensure all personal and healthcare needs are met. EVIDENCE: As mentioned previously the home is liaising with a number of other agencies, including health services ensuring individual and specialist needs are responded to appropriately. The community nurse is working closely with the home to complete a detailed assessment and give advice and guidance on an ongoing basis. They have helped to develop detailed strategies and flow charts, to support and guide staff in responding consistently to the complex and challenging behaviours of one resident. All the residents are registered with a GP of their choice and are supported or prompted by staff to attend both routine and one off appointments. The majority of medication in the home is managed in a monitored dosage system, with appropriate records maintained of all medication administered including PRN medication. When I examined these records it was evident they had not been fully completed with gaps left and medication not signed for on two days. It is recommended the home review their checking system so that any errors are noted at the earliest opportunity. Resident’s weight is monitored on a two weekly basis and appropriate actions taken when changes are recorded. Shepherds Lodge DS0000022629.V275671.R01.S.doc Version 5.1 Page 13 The home has completed a user-friendly document recording people’s wishes upon death. It is in a pictorial format and records all relevant personal and family wishes. Shepherds Lodge DS0000022629.V275671.R01.S.doc Version 5.1 Page 14 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): 22, 23 These standards were met at the last inspection. EVIDENCE: There have been no complaints since the last inspection. Shepherds Lodge DS0000022629.V275671.R01.S.doc Version 5.1 Page 15 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): 24, 28, 29, 30. Shepherds Lodge provides a safe and comfortable environment. The planned work will improve access to and from the home. EVIDENCE: 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. Work on the front driveway and path has been planned and should be completed by June 06. Improvements are also planned for the rear patio area, which will improve the access and egress from the rear French windows. The new arrangements with the layout of the home have worked well and residents appeared to be comfortable in their home. Since the last inspection the home has been visited by an occupational therapist who completed an assessment for one of the residents and recommended specific aids and adaptations. Shepherds Lodge DS0000022629.V275671.R01.S.doc Version 5.1 Page 16 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. Shepherd’s Lodge provides a consistent and reliable service to residents who needs are being appropriately met. EVIDENCE: The home continues to provide appropriate levels of staff to support the residents. The home benefits from having a consistent and reliable staff group who have developed a good understanding of the resident’s individual needs and are clear what their role and responsibilities are. The home maintains a record of all training courses attended and certificates of achievements. The newest member of staff had just completed the Learning Disability Award Framework (LDAF) induction and foundation course. References had been received and an up to date CRB disclosure obtained. The manager provides both formal and informal supervision to staff with records maintained. The staff said the “manager is always available and responds to issues raised” and “we get good support”. The home also holds staff meetings and has good systems in place to share information amongst the staff team. Shepherds Lodge DS0000022629.V275671.R01.S.doc Version 5.1 Page 17 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, 42. The manager and the staff team ensure the efficient and effective management of the home. The needs of residents are responded to appropriately and their rights respected at all times. EVIDENCE: The manager and staff work very closely together and support each other in providing a personalised service. There is a high level of commitment shown by the staff to ensure individual needs are responded to in a consistent manner and residents are supported to achieve their goals. The manager is reviewing the format of the resident’s survey questionnaire to improve its effectiveness in gaining meaningful feedback. Previously the home has engaged independent advocates to support the residents in completing the questionnaire. It was evident from my observations and discussions with residents they have a lot of autonomy in choosing how they live their lives. The manager was aware of potential hazards when completing work to the driveway and rear step and was managing these on an ongoing basis with the involvement of residents and staff. Work is planned for completion in June 06. Shepherds Lodge DS0000022629.V275671.R01.S.doc Version 5.1 Page 18 The home currently has one vacancy, however the manager was keen to get the newest resident settled into life in the home before considering filling the vacancy. Shepherds Lodge DS0000022629.V275671.R01.S.doc Version 5.1 Page 19 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 2 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 3 25 X 26 X 27 X 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 3 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 2 3 3 3 3 X X 3 3 Shepherds Lodge DS0000022629.V275671.R01.S.doc Version 5.1 Page 20 Yes 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 YA5 Regulation 5 Requirement The home must issue a new contract of terms and conditions in line with the National Minimum Standards. Timescale for action 01/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA20 Good Practice Recommendations It is recommended the home review their checking system for medication so that any errors are noted at the earliest opportunity. Shepherds Lodge DS0000022629.V275671.R01.S.doc Version 5.1 Page 21 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.V275671.R01.S.doc Version 5.1 Page 22 - 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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