Inspection on 18/01/06 for South Lodge

This inspection was carried out on 18th January 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

South Lodge 23/08/06

South Lodge 20/10/04

South Lodge 18/05/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 South Lodge 2 Sidney Road Bedford Bedfordshire MK40 2BG Lead Inspector Mr Pursotamraj Hirekar Unannounced Inspection 19th January 2006 03:30 South Lodge DS0000014970.V272283.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 South Lodge DS0000014970.V272283.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. South Lodge DS0000014970.V272283.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service South Lodge Address 2 Sidney Road Bedford Bedfordshire MK40 2BG 01234 312432 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) H4037@mencap.org.uk Royal Mencap Society Mrs Jill Cooper Care Home 8 Category(ies) of Learning disability (9) registration, with number of places South Lodge DS0000014970.V272283.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The manager must complete an NVQ 4 in care by 31st December 2005. Date of last inspection 30th August 2005 Brief Description of the Service: New Era Housing Association with whom those living at the home have a lease owns the property. Mencap provides the Service. It is a detached Victorian building with an annexe. The main building provides accommodation for seven service users. It has two floors. On the first floor there are five service users’ rooms, a bathroom with toilet and hand-basin, separate toilet with hand-basin, and a staff office/sleep-in room. On the ground floor there are two service users’ rooms, a lounge, a kitchen/dining room, a bathroom with a toilet and hand-basin, and a laundry room. There is an annexe (2a Sidney Road), which provides a more independent living environment for a service user. It has a bedroom, a lounge/dining room and a kitchen. Attached to the annexe is a building used as an office for both 2/2a Sidney Road. The appointed manager is also the mnager for 11 Sidney Road, which is also a registered care home. There is also an enclosed garden. The building and grounds are owned by New Era who are responsible for their upkeep. South Lodge is located in a residential area of Bedford. It is in walking distance of the town centre with all the amenities of a large town including a bus and railway station. A main railway line runs by the side of the house. South Lodge DS0000014970.V272283.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the report of the unannounced inspection commenced at 3.30pm on 18.01.06 by PursotamRaj Hirekar and lasting over 2 ½ hours. The manager and support staff coordinated the inspection. The methodology of the inspection included study of care plans, risk assessments, review documents, business plans and various health and safety checks documents, conversation with service users, discussion with manager and support staff and tour 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. South Lodge DS0000014970.V272283.R01.S.doc Version 5.0 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 South Lodge DS0000014970.V272283.R01.S.doc Version 5.0 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): None EVIDENCE: South Lodge DS0000014970.V272283.R01.S.doc Version 5.0 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): 7, 8, 9 The home must continue, to ensure the qualitative good work of risk assessments, care plans and reviews to meet the changes and developments of service users’ needs. EVIDENCE: The service users’ whose care plans, risk assessments and reviews were examined provided evidence of comprehensive and up to date. Especially, the reviews conducted had the benefit of participation of service users, family members, friends, associated professionals and home staff. The various stakeholders participation had enabled the service providers to do a comprehensive review of the service users care plan and risk assessments in the best interest of the service users, and dovetail results into an action plan for implementation. South Lodge DS0000014970.V272283.R01.S.doc Version 5.0 Page 9 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): None EVIDENCE: South Lodge DS0000014970.V272283.R01.S.doc Version 5.0 Page 10 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 The home must ensure the changing health care needs of service users are promptly met. EVIDENCE: The home had made appropriate arrangements to provide personal support the way service users prefer and require. Service users health care needs were assessed and reviewed with the help of qualified professionals and were systematically documented and actioned. The trained staff administer medication to the service users. However, the current health care needs of the service users and the available staff on duty ratio needed to be reviewed to ensure that the changing health care needs of the service users are promptly met. South Lodge DS0000014970.V272283.R01.S.doc Version 5.0 Page 11 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): 23 The home must ensure staffs have received training in POVA and the service users’ are protected from any risk. EVIDENCE: The home had made arrangements for staff training in moving and handling, first aid, fire safety, infection control, food hygiene, dementia, person centred planning. However, no staffs have received POVA training. The home must ensure that staffs have received POVA training to prevent any abuse and neglect of the service users. South Lodge DS0000014970.V272283.R01.S.doc Version 5.0 Page 12 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, 30 The service users live in a clean, hygienic, homely and comfortable environment. EVIDENCE: The service users live in a homely, comfortable and safe environment. The health and safety checks were carried out on a weekly and monthly basis. They include hot and cold water, doors, extinguishers, and drugs, smoke alarm, fire alarm, electrical appliances, shower, and first aid kit. However, the emergency lighting needed regular checks. The dining area, lounge, hallways, two bathrooms and one toilet were redecorated. The service users were satisfied with the redecoration. The home was clean and hygienic. South Lodge DS0000014970.V272283.R01.S.doc Version 5.0 Page 13 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): 32, 33, 34, 35 The current staffs worked as a team to ensure service users’ needs are not overlooked. The home must ensure that there are adequate staff all the time to ensure that the service users’ changing needs are met. EVIDENCE: The home had qualified staff and were appropriately supervised by the manager to ensure teamwork and that they contributed effectively for the well being of the service users. Currently, the home had 2 service users with epilepsy, 2 service users with dementia and 1 service user with autism apart from all the service users having learning disabilities. The service user who lives in an annexe semiindependently had epilepsy and dementia and is on medication. This service user was at risk especially during night as there were no staff to attend in case of emergency at night. The current emergency system had to complete a lengthy process before the service user was attended. The manager had provided evidence to support that in the last 6 months the health needs of service users have increased and the home had encountered staff shortages and have also noted in the annual business plan. The manager had made attempts with the management to add additional staff members to the home South Lodge DS0000014970.V272283.R01.S.doc Version 5.0 Page 14 and said that there was no positive commitment yet from the management to add additional staff. South Lodge DS0000014970.V272283.R01.S.doc Version 5.0 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, 42 The home was managed well to promote the interests of the service users. EVIDENCE: The home had appointed a new manager and was working since June 2005. The manager had NVQ4 in management and 16 years of experience working with the disabled in the social care industry. The home was managed well and the interests of the service users were safeguarded. The business plan drawn up for the year 2005/2006 was comprehensive had entailed information on the changes and developments that were taking place at the home and in the life of the service users. The work on the annual business plan was a useful effort to demonstrate how the home promoted the well being of the service users. However, an action plan that would enable the manager and staffs of the home to address any emergency needs of the service users promptly and effectively needed attention. South Lodge DS0000014970.V272283.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score X 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X 3 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 2 3 3 x CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 South Lodge Score 3 2 3 X Standard No 37 38 39 40 41 42 43 Score 3 X X X X X 3 DS0000014970.V272283.R01.S.doc Version 5.0 Page 17 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 YA23 Regulation 13(6) Requirement The home must ensure staff are trained in POVA to prevent service users being harmed or being placed at risk of harm or abuse The home must ensure that staff are working in such numbers as are appropriate for the health and welfare of service users in accordance with guidance recommended by the Department of Health. Timescale for action 31/03/06 2. YA33 18 (1)(a) 31/03/06 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 South Lodge DS0000014970.V272283.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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 South Lodge DS0000014970.V272283.R01.S.doc Version 5.0 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. 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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