Inspection on 23/08/06 for South Lodge

This inspection was carried out on 23rd August 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

South Lodge 18/01/06

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 23rd August 2006 04:15 South Lodge DS0000014970.V307872.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 South Lodge DS0000014970.V307872.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. South Lodge DS0000014970.V307872.R01.S.doc Version 5.2 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) www.mencap.org.uk Royal Mencap Society Care Home 8 Category(ies) of Learning disability (9) registration, with number of places South Lodge DS0000014970.V307872.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 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 manger for 11 Sidney Road, which is also a registered care home. There is also an enclosed garden. New Era who is responsible for their upkeep owns the building and grounds. 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.V307872.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the report of the unannounced key inspection carried out on 23/08/06 and 25/08/06 over 5 hours by pursotamraj hirekar. The method of inspection included review of outstanding recommendations, study of care plans, risk assessments, staffs’ files. Discussion with the service users’, staffs on duty and the manager, partial tour of the premises and observations. The manager and a support worker had coordinated the entire inspection. 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.V307872.R01.S.doc Version 5.2 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.V307872.R01.S.doc Version 5.2 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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The statement of purpose and service user guide enabled potential service users to make informed decisions. EVIDENCE: Service users’ guide was reviewed on 01/01/06 and is comprehensive. There has been no new admission since the previous inspection. South Lodge DS0000014970.V307872.R01.S.doc Version 5.2 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 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had reviewed the risk assessments and updated the careplans to incorporate the changing needs and aspirations of the service users’. EVIDENCE: On this inspection 3 service users’ were case tracked following are the details: Service user – 1 support plan was detailed with plan of action to meet the service users’ assessed needs which included information about relationships, money management, mobility/ travel, epilepsy management, additional health and safety support needs, using stairs, religious and cultural, day opportunities, social and leisure, identified goals for the coming year, long term goals and aspirations, photograph, communication and wellbeing, sensory needs, audiologist, dentist, chiropody, occupational therapy, dietary needs, GP support. The support plan was reviewed and updated 27/06/05, 05/01/06, 24/07/06, 27/07/06, 22/09/05, and the recent was on 04/08/06 signed by the manager and the support staff. Service user – 2-support plan was prepared on 03/03/05 and reviewed on 12/03/06 and 14/07/06. The support plan had detailed information on South Lodge DS0000014970.V307872.R01.S.doc Version 5.2 Page 9 communication / emotional needs, health needs, relationships, money management, religious/cultural needs, social/leisure, mobility/travel, day opportunities, domestic routines, identified goals for the coming year, longterm goals, dreams and aspirations. Annual review was carried out on 07/02/06 the participants include service user, manager, support staff, student nurse and reviewing officer. The review covered aspects such as current needs and services, what works well, what the service user would like to change and agreed action. Risk assessments were carried out for money management on 13/07/06, managing autism on 14/07/06, bathing unsupervised on 15/07/06 and kitchen on 15/02/07. Service user – 3 support plan was detailed with plan of action to meet the service users’ assessed needs which included information about relationships, money management, mobility/ travel, epilepsy management, additional health and safety support needs, using stairs, religious and cultural, day opportunities, social and leisure, identified goals for the coming year, long term goals and aspirations, photograph, communication and wellbeing, sensory needs, audiologist, dentist, chiropody, occupational therapy, dietary needs, GP support. Risk assessments were carried out for walking night support on 03/03/06, personal safety outside the home 01/03/06, personal safety in the event of fire on 01/03/06, managing dementia on 06/12/05, daily fluid and food intake on 06/12/05, accessing stairs in the home on 21/12/05, accessing bathroom on 01/03/06 and choking when eating on 01/03/06, South Lodge DS0000014970.V307872.R01.S.doc Version 5.2 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): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had consultations with all service users’ and developed activites that meet the individual service users’ needs and aspirations to achieve quality of life goals. Except for one service user. EVIDENCE: The home had made appropriate arrangements for day care opportunities for the service users’ and their details are as below. Service user – 1 on Monday, Wednesday and Friday attend kemps ton centre. Had visited Zoo in September 2005. Enjoyed the company of other service users’, like to go to the supermarket, enjoyed going out for a meal and drink and enjoyed listening to others talk at the home and socialising with the family. Service user – 2 does not have any other people that she refers to as her friends other than a home visitor, who visits once in three months to see. Service user does most of the domestic activities on her own which include using kitchen, laundry, ironing, bedroom chores, cooking and general house work. The staffs support the service user for bank operations and shopping. The service user social and leisure activities were limited her bedroom South Lodge DS0000014970.V307872.R01.S.doc Version 5.2 Page 11 watching TV, drawing pictures, and knitting clothes. However, attends St Marks Club house on Monday, Wednesday and Friday. Tuesday and Thursday no specific activity but the staffs support service user to go out and about. Service user – 3 has a sister with whom she has occasional contact and receives gifts for Christmas. She needs the support of the staffs to maintain contacts with her family members. She enjoys the company of other service users’ in the communal areas. She needs support of staff for money management including obtaining receipts and any payments. The service user enjoyed watching TV at the home, need help of the staff to explore and help with activities that help personal development. She can access only the ground floor and the staffs needs to be aware of her where about in the home as she is vulnerable with regard to mobility. She spends most of the time at the home watching TV, and relaxing and with occasional trips out. Staffs need to identify and offer opportunities to routine the day of the service user. She needs support from the staffs for washing up, laundry, ironing, cleaning bedroom and cooking. South Lodge DS0000014970.V307872.R01.S.doc Version 5.2 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 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The assessed personal and health care needs of the service users’ were met as per the care plan. Except for 1 service user. EVIDENCE: Service user –1 has been in the hospital for 2 weeks and the hospital had said that they couldn’t discharge to be accommodated at south lodge due to his increased health needs. The family, social services, hospital authorities and the manager had judged that the service user couldn’t be accommodated at south lodge due to his increased needs. Medication procedure was reviewed and update on 22/8/5, 12/9/05 and 4/7/6. Mars sheet were seen and the records found updated. Service user was sleeping in the lounge for 10 days before he was hospitalised due to an infection. Service users’ contract with the home contract had not specified details with regard to provision of services when the needs of the service users’ increase or if the home cannot provide services matching the assessed needs of the service users’. The home needs to revisit the service users’ contract terms and conditions and make appropriate amendments. Manager had spoken to the Area Manager during this inspection and said that area manager would discuss with the social services regarding termination of contract and inform the commission on the status. South Lodge DS0000014970.V307872.R01.S.doc Version 5.2 Page 13 The commission had received a letter from the area manager on the 31/08/06 stating that the Social Services and Mencap are in agreement that on no account can the service user be discharged back to the service at the home. In another letter to the commission signed by the manager dated 07/09/06 had mentioned that the service user was being discharged on the 07/09/06 and moving directly to a Nursing home. Service user – 2 the manager and the support staff on 27/7/6 have conducted risk assessments. Moving and handling issues have been identified in the assessment date 01/08/06 the person conducted the assessment has not signed and recommended for an OT’s assessment. Chiropody, optometrist, dentist, GP support, Doctor/Nurse/Psychiatrists visits record were maintained. Service user – 3 has dementia and Down syndrome, and currently receiving support from the Twin woods and is on medication. Service user needs home staff to support and monitor all her health appointments that include Chiropody, dentist, optician and GP support. Record of professional and medical treatment was maintained that include doctor, optician and chiropodist. The annual care plan was reviewed on 17/09/05 the participants included service user, support staff, reviewing officer and manager. The care plan recorded in the action agreed sections that ‘provisional proposal regarding increase in care support to be drafted by area manager’. Support plan with regards how the home can meet dementia needs through training and staffing to be drafted by Area manager’ this agreed plan was to be achieved by three months from the date of the review i.e. 17/09/05. There was no evidence to this effect and the dementia review was also outstanding. South Lodge DS0000014970.V307872.R01.S.doc Version 5.2 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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had made appropriate arrangements with regard the complaints policy and procedures. EVIDENCE: The home had a comprehensive complaints policy and procedure with appropriate pictures for easy understanding. There were no complaints since, the previous inspection. South Lodge DS0000014970.V307872.R01.S.doc Version 5.2 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 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home had not met the assessed needs of 1 service user and the service user was at risk of harm. The health and safety checks of the home were carried out. EVIDENCE: One service user was moved from his bedroom to the lounge, for 10 days he used the lounge as his bedroom causing inconvenience to himself and other service users’ as well. Please refer personal and healthcare support outcome group for more information on this. The health and safety checks carried out by the home were work place monthly inspection checks latest dated 25/08/06 and were regular. Hot and cold-water temperature checks currently done monthly and the home is planning from beginning September 2006 to do weekly. Smoke alarm check was done weekly, fire alarm test was done weekly, hot water thermostat testing done weekly, fire extinguisher inspection was done weekly, first aid kits contents checked monthly and emergency lighting was done monthly. South Lodge DS0000014970.V307872.R01.S.doc Version 5.2 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): 32, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had a good skill mix of staff that complemented service users’ particpation. EVIDENCE: The home had appointed 2 new staffs since the previous inspection. The statutory checks found on this inspection-included application, CRB, reference2, and medical. The manager had said that the contract documents were at the central office. Currently, both the staffs were under going induction. The home had a robust induction programme. Staff training – updated on the 17/05/06 all the staffs now have received POVA training. 6 staffs training needs have been identified and appropriate training was given. Discussion with a support worker was held on this inspection and the details are as follows: Staff –1 working as support worker since 03/05/05, her responsibilities included, act as key worker to 2 service users’, act as team leader at times when required, in charge of a shift which involve responsibilities for medication, doing petty cash and food. Trainings received were fire, cosh, first aid; person centred planning, pova, manual handling, and foot care, administration of diazepam and in-house training on medication. Had supervision once in every two months. Suggested that the need for more regular team meetings with staff to discuss the problems and issues among staff to be resolved. She was happy working at the home in a team spirit and with the service users. South Lodge DS0000014970.V307872.R01.S.doc Version 5.2 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, 39 and 42 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. The home was managed well. The manager and the staffs work as a team in the interest of service users’. However, 1 service users’ assessed needs were not met. EVIDENCE: The manager and the staffs work as a good team in the interest of the service users’. Staff supervision planned every monthly at times supervision get delayed and takes place once in 6 weeks. The new manager was working since June 2005 had NVQ4 in management and 16 years of experience working with the disabled in the social care industry. In general the home was managed well in the interest of the service users’. However, 1 service user who was allowed to sleep in the lounge for 10 days is not a good practice and was not in the interest of any service user at the home. The home must not repeat any of these experiences again. South Lodge DS0000014970.V307872.R01.S.doc Version 5.2 Page 18 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.V307872.R01.S.doc Version 5.2 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 3 X 2 X 3 X X 3 X South Lodge DS0000014970.V307872.R01.S.doc Version 5.2 Page 20 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 YA19 Regulation Reg12 Requirement The home must ensure that appropriate procedures are in place to address the assessed and recognised healthcare needs of the service users. The home must ensure that the bedrooms and lounge are suitable and meet service users’ individual and collective needs and no single service user is allowed to use lounge as a bedroom. The home must ensure on time to complete service user support plan with regards, how the home can meet dementia needs through training and staffing. Timescale for action 25/09/06 2. YA24 13(4)(5) 23(2) 15/09/06 3. YA18 12(1) 25/09/06 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 YA37 Good Practice Recommendations The home should ensure that each and every service users’ has a written contract of terms and conditions and DS0000014970.V307872.R01.S.doc Version 5.2 Page 21 South Lodge 2. YA13 that the terms of the contract are fulfilled. The home should ensure all the service users’ are supported to become part of, and participate in, the local community in accordance with assessed needs and the individual plans. 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