Inspection on 23/05/07 for St Davids Lodge

This inspection was carried out on 23rd May 2007.

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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

St Davids Lodge 19/05/09

St Davids Lodge 21/05/08

St Davids Lodge 16/05/06

St Davids Lodge 02/11/05

St Davids Lodge 01/06/05

St Davids Lodge 08/02/05

St Davids Lodge 26/08/04

St Davids Lodge 04/02/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOMES FOR OLDER PEOPLE St Davids Lodge 98 Lodge Causeway Fishponds Bristol BS16 3JP Lead Inspector Sandra Jones Unannounced Inspection 09:30 23 and 29th May 2007 rd X10015.doc Version 1.40 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 St Davids Lodge DS0000026625.V337521.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 Older People. 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. St Davids Lodge DS0000026625.V337521.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Davids Lodge Address 98 Lodge Causeway Fishponds Bristol BS16 3JP 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) 0117 9656965 0117 9656965 hazelprycejones@hotmail.com Mrs Hazel Lilian Pryce-Jones Mr Clive Pryce-Jones Donald Edward S W Graham Care Home 11 Category(ies) of Learning disability (11), Learning disability over registration, with number 65 years of age (11) of places St Davids Lodge DS0000026625.V337521.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 11 persons aged 50 years and over Date of last inspection Brief Description of the Service: St Davids Lodge is a care home for people with learning disabilities. Since conducting the last inspection, the service provider has sought to increase the registered numbers. The application was successful and the home is now registered to accommodate 11 people with learning disabilities over 50 years. The property is situated on the Lodge Causeway, close to the Fishponds Road, shops, other amenities and bus routes. The property is detached and arranged over two floors with shared space on the ground floor and personal space on both floors. It has the appearance of a domestic dwelling and blends well with its local environment. St Davids Lodge DS0000026625.V337521.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was conducted unannounced over two days in May 2007 and focused on the assessment of key standards. The main purpose of the visit was to check on the welfare of the people who use the service, ensure the premises are well maintained and to examine health and safety procedure. During the site visit, the records were examined, a tour of the premises was conducted and feedback sought from individuals and staff. Eleven completed “Have your say” surveys were received at the Commission from people who use the service. Feedback from relatives and Health and Social Care Professionals was sought through comment cards. One comment card was received from the GP and one from the Community Learning Disabilities team (CLDT). Prior to the visit some time was spent examining documentation accumulated since the previous inspection, including the pre-inspection questionnaire and notified incidences in the home, (Regulation 37’s). This information was used to plan the inspection visit. Four people were case tracked during the inspection. Case tracking is the method used to assess whether people who use services receive good quality care that meets their individual needs. The inspection included looking at records such as care plans and reviews of the care of people using the service and other related documents. The home’s policies and procedures were also used to confirm the findings. The views of the manager, staff and people using the service were gathered either by face- to- face discussions or by surveys. What the service does well: There is a relaxed atmosphere and people living at the home are supported to lead active and interesting lifestyles. The people at the home confirmed that they have the confidence to approach staff and the manager with complaints. Their comments indicate that staff take their concerns seriously and act upon them. Other comments indicate that meals served are good and there are staff available at the home at all times. St Davids Lodge DS0000026625.V337521.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: While it is acknowledge that the care planning system is improved, action plans must be expanded with more detail to guide members of staff to consistently meet the identified needs. It is acknowledged that the home has installed equipment to ensure that people living at the home can move around the home independently. However, the staff must ensure that the individual’s privacy and dignity is maintained. The manager must ensure that individuals have privacy and dignity when they undertake personal care without staff support. Individual medication profiles that list the name of the prescribed medication, its purpose and compatibility with homely remedies must be must be formulated. This will ensure that individuals at the home are safeguarded by good practice. St Davids Lodge DS0000026625.V337521.R01.S.doc Version 5.2 Page 7 Policies and procedures that relate to aggression, violence and restraint must be reviewed to ensure that they meet current good practice guidance. Members of staff must be skilled to manage violent and aggressive behaviours and care plans must be clear about the approach to be adopted by the staff. Action plans must be detailed and guide the staff to consistently manage potentially aggressive situations. It is evident that the premises are well maintained. However, the area to the rear of the property would benefit from attention. The views of the individuals at the home must be sought about what would best suit them before any action is taken. The recruitment process must be more stringent to ensure that only people that are suitable to work with vulnerable adults are employed. The manager must establish that the person with convictions is fit to work at the home. A Quality Assurance cycle that reflects the views of the people at the home and monitors the success of the aims and objectives of the home must be introduced. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Davids Lodge DS0000026625.V337521.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Davids Lodge DS0000026625.V337521.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There is an efficient admission procedure, which ensures that people moving into the home have enough information to make decisions about living at the home. EVIDENCE: The Statement of Purpose confirms that offers for accommodations are only accepted from Local Authority referrals and all admissions are based on full assessments from the care coordinator. Four people moved into the home since the last inspection and their case records were examined during the site St Davids Lodge DS0000026625.V337521.R01.S.doc Version 5.2 Page 10 visit. Case records examined indicate that social workers and pre assessments were conducted in advance of the admission to the home. Initial assessments and care plans were developed by the home during the trial period. The signature of the individual is an indication that the person agrees with the plan of action. “Have your Say” surveys were sent to the home before the site visit and eleven were received from people living at the home. Surveys state that they received enough information about the home to assist them with making decisions about moving into the home. Comments made in the survey included “ I came for a visit before I decided” and another stated, “ I spent a day and night here to make up my mind and I asked questions.” The two individuals that recently moved into the home described the process followed before admission to the home. Both individuals confirmed that introductory visits took place and information about the home was provided. Individuals stated that their representatives accompanied them to help them make decisions about moving into the home. St Davids Lodge DS0000026625.V337521.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The care planning systems is clearer for staff to follow and people living at the home receive individualised care. It would benefit from having more detailed information so that individuals at the home can benefit from receiving a consistent service. People at the home can expect sensitive and prompt support for their personal and health care needs from a skilled staff team. Medication systems are safe. EVIDENCE: The care plans are up to date and based on all areas of need including personal, social, emotional and intellectual. The signature of the person indicates their understanding with the plan of action. A care review form is used to record the dates of reviews, amendments made to the care plan, views of the person, the people involved and their signatures. “Have your Say” St Davids Lodge DS0000026625.V337521.R01.S.doc Version 5.2 Page 12 surveys from individuals at the home state that they receive the care and support they need. The manager explained that the format was changed for staff to have an action plan that they can follow. Two people were consulted about the way their needs are met by the staff. Both individuals were able to name their keyworkers and describe the role they performed. It was stated that keyworkers undertake 1:1’s, maintain bedrooms tidy and check clothing. Keyworkers on duty confirmed that they undertook these tasks. Both people consulted about the care planning process and neither could remember for this reason their care plans were used as prompts. For one person the care plan was sufficiently detailed for the person to give feedback on the care provided by the staff. The care plan for the other person was not as detailed, for the person to fully comment on the consistency of care provided by the staff. Care plans must be further developed to ensure that action plans clearly direct staff to consistently meet identified needs. Consideration must be given to using a format that can be understood by the person. Health and personal care needs are listed within the care plans and documentations shows that health care professionals are involved in the care of the individual. Health care needs are listed within the care plan and the advice to be followed incorporated into the plan of action. For individuals with mobility impairments, their care plans direct staff on the actions that must be taken to meet their needs. The GP stated through the comment cards that “The home goes from strength to strength, communication is good and the staff are caring,” and the Occupational therapist stated “ on visiting or any consultation recommendations have been acted upon.” “Have your Say” surveys from individuals at the home state that they always receive the medical support they need. Individuals consulted during the site visit stated that staff accompanies them when health care visits take place. The individuals at the home have access to NHS facilities, regular visits to the dentist, and chiropodist and optician are arranged. A monitored dosage system is used by the staff to administer oral medications. The records indicate that staff sign the medication records immediately after administering medications in the system. However, gaps were found in the administration records of topical creams and inhalers. A record of medications no longer required is maintained and signed by the pharmacist to indicate receipt of the medication for disposal. Individual medication profiles are not currently in place. The manager must develop medication profiles for each person on prescribed medications, which list the medication prescribed, their purpose and side effects. Medication leaflets about the medication must be appended onto the profile. St Davids Lodge DS0000026625.V337521.R01.S.doc Version 5.2 Page 13 medicine prescribed must also be available to staff. The manager must seek medication leaflets from the pharmacist to ensure the individuals at the home are safeguarded from abuse. The Statement of Purpose defines the Principles of Care, which incorporate privacy and dignity. The service provider said that there is an expectation that staff read policies and procedures regarding privacy and dignity during the home’s induction programme. Staff’s signatures are included within the manual as an indication of their awareness and understanding of the procedure. The manner in which individuals privacy and dignity is respected was assessed during the site visit. Within the case records, individuals preferred mode of address is included. One room is currently sharing and ensuite facilities are provided to ensure privacy is not compromised while personal care is provided. Care plans are clear about the manner in which staff must provide personal care to the individual. Feedback was sought from two individuals about the way their right to privacy and dignity is maintained by the staff at the home. One person stated that the provision of single lockable bedrooms, the way staff speak to individuals living at the home and the way personal care is provided ensured their privacy and dignity was respected. Another person confirmed that single lockable bedrooms and the provision of equipment and aids to be independent with personal care respected their privacy and dignity. However, this individual stated that they did not close the bathroom door when they are having a bath. It is acknowledged that this individual is independent and can bathe without staff support. The manager must, nevertheless, ensure that this individual has privacy. An assessment must therefore be undertaken to ensure their privacy is maintained. St Davids Lodge DS0000026625.V337521.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There are good support systems in place for individuals to lead active and interesting lifestyles. EVIDENCE: The service provider stated that house meetings that take place monthly are the forums used to discuss activities, outings and holidays, with the individuals living at the home. The records of house meetings were examined and confirmed that holiday arrangements, day trips to places of interest and inhouse activities are discussed with the individuals during the meeting. Opportunities also exist during the meetings for each person to discuss their weekly activities. Six people currently attend day care centres, college courses and evening clubs. Planned in-house activities take place each day and include arts and crafts, bingo and board games, with disco evenings and sing-along taking place at weekends. From the records of daily activities, there are more St Davids Lodge DS0000026625.V337521.R01.S.doc Version 5.2 Page 15 opportunities for individuals living at the home to experience meaningful activities. Ten “Have your Say” surveys state that activities are always arranged and they can take part. Three people stated in the surveys that they attend clubs, go on holiday and attend day care centres. Two individuals were consulted about living at the home and it was stated that they attend community-based activities twice weekly. For one person writing, taping and computing were activities undertaken at the home. Knitting and watching television are the activities undertaken by the other person. Routines for daily living are included within the person’s case records. Both individuals said that they can rise and retire when they wish. The Visitors Policy is included within the Statement of Purpose and Terms and Conditions of residency. The policy states that visitors are welcome at any reasonable time and there is an expectation that visitors sign the visitor’s book. The name of the person visiting the home, the nature of their visit and their signature is included within the visitor’s book. One “Have your Say” survey was received from relatives and it states that they home always support individual to maintain contact with them. The two people consulted, agreed that the staff welcome their visitors and their visitors can go to their bedrooms for additional privacy. Policies and procedures that relate to financial management and confidentiality are in place and aim to protect the individuals living at the home from abuse. The Statement of Purpose informs people that personal belonging can be taken into the home to make personal space more homely. One person consulted about taking personal items into the home stated, “ I brought in a picture of Concord that I had before I came to the home”. The other person stated that they took their computer equipment into the home during their admission. The service provider stated that advocates are not currently used at the home. In term of confidentiality, procedures about personal and passing information is clear about staff expectation to maintain individuals personal information private. The right to access records is also stipulated within the procedure, for information to be meaningful to the people living at the home, formats that can be easily understood must be used. The individuals ability to manage their finance is specified within their care plan. One person consulted explained that the have weekly personal allowance and assistance with budgeting is provided by the manager. Another person stated that their family have Power of Attorney over all their finances. Feedback about the food served at the home was sought from two individuals. It was stated that the food is good and alternatives to the meals served are offered. One person explained that a diabetic diet is provided and the other stated that they prefer small portions and no puddings. Seven “Have your Say” surveys indicate that the individuals living at the home always like the St Davids Lodge DS0000026625.V337521.R01.S.doc Version 5.2 Page 16 meals served. Two stated that they usually like the meals and one stated sometimes. There is a list of each individuals likes and dislikes on display in the kitchen to ensure that meals are suitable to the person living at the home. The four-week rolling menu in place, range of food kept at the home and record of food provided confirmed that individuals have a varied diet. St Davids Lodge DS0000026625.V337521.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People living at the home can expect their concerns to be listened to. For individuals to be protected from abuse, strategies must be developed for people that at times exhibit aggression. EVIDENCE: The Complaints procedure is included in the Statement of Purpose and Terms and Conditions of Residency. Copies of the complaints procedure are on display in the foyer of the building. While the procedure is in large print and simple format, the manager must ensure that people for whom it’s intended can understand the procedure. Three complaints were received at the home since the last inspection. Two were from a parent of a person living at the home about the environment. The other was from an individual living at the home about another person that also lives at the home. Nine “Have your Say” from individuals at the home state that they always know who to speak to if they are not happy and how to make a complaint. Four people specified the person they would approach with their complaints. One relative survey was received and indicated that they were not aware of the home’s complaint procedure but the home had always responded appropriately to the concerns raised. Both individuals at the home stated the St Davids Lodge DS0000026625.V337521.R01.S.doc Version 5.2 Page 18 name of the person that they would approach with complaints and one person also explained that a procedure is available. During the consultation with the individuals at the home, it transpired that that one person might at times become verbally aggressive. One person stated, “ the swearing upsets me and I have to go to my room because I don’t like it.” It is evident from the comments made by this person that one individual at times will shout and use inappropriate language. Through discussion with the manager it was stated that one person can at times exhibit aggressive behaviour and guidelines from the previous home are in place. There is a Management of Violence procedure in place, which requires updating to ensure practices followed at the home are appropriate and staff have the skills to use the techniques. Members of staff must attend training to increase their abilities to manage potentially aggressive situations. For incidents of aggression to be consistently addressed, a strategy must be developed on the way incidents are to be managed by the staff. Policies and procedure about abuse, “No Secrets” and Code of Conduct set the approach for safeguarding adults from abuse. The abuse policy requires further development to ensure it follows “No Secrets” guidance. The service provider stated that there were no POVA referrals involving staff and people living at the home. St Davids Lodge DS0000026625.V337521.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is well maintained and for people living at the home to benefit from living in a homely environment their feedback must be sought. . EVIDENCE: St David’s Lodge is located on Lodge Causeway, close to the Fishponds Road, shops, amenities and bus routes. The property is surrounded by residential and industrial environment; it maintains an appearance of a domestic dwelling. It is arranged over two floors with bedrooms on both floors and shared space on the ground floor. St Davids Lodge DS0000026625.V337521.R01.S.doc Version 5.2 Page 20 Shared facilities consist of a lounge/dining area and conservatory. The lounge has seating for eleven residents and in the dining room there is sufficient seating for the residents to have their meals together. The conservatory is used for in-house activities and can seat up to four residents. Since the last inspection the flooring in the communal areas was replaced and sofas were purchased for the lounge. Vanity units were installed in all bedrooms so the toiletries can be stored and bedroom furniture was replaced in a number of bedrooms. Members of staff and individuals living at the home were consulted on the input they had in the selection of the sofas for the lounge. It was understood from the staff including the manager and individuals living at the home that they had no input into the selection of the sofas. It is evident that alternations continue to be made to ensure the property is homely and comfortable. During the inspection it was noted that repairs were taking place to ensure the property is safe for the people living at the home. While the property is maintained to suit the people living at the home, the exterior would benefit from attention. The service provider must consult the people living at the home about how the outside area to the rear of the property would best suit their needs. Two individuals were consulted about their personal space and both individuals stated their satisfaction with their accommodation. One person stated that in their bedroom they had their own television, music centre and the other said they had computer equipment. During the consultation it was stated that a computer desk was needed to make their personal space more comfortable. The manager stated that the purchase of a desk was part of this individuals care planning. The laundry room is sited upstairs away from the kitchen. The floor covering is impermeable and the walls are painted making the surface readily cleanable. The washing machine is suitable for the number of residents accommodated and has a specified programme for disinfection Nine “Have your say” surveys from people living at the home state that the home is always fresh and clean. St Davids Lodge DS0000026625.V337521.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A competent, qualified and skilled staff team who are well supervised supports the people at the home. EVIDENCE: Two people are rostered from 7:30-9:30 with senior staff and the manager. The rota in place indicates that support staff work in shifts of 7:30-2:30 and 2:30-9:30 while senior staff work 9:00-4:00. There is person rostered at night to undertake waking nights and ancillary staff work 9:30-3:30 five days per week. The manager stated that by senior staff working office hours the individuals at the home could attend appointments and participate in activities. The two senior staff were consulted about their role at the home. It was stated that they manage the shift, ensure people attend appointments, supervise staff with tasks and attend reviews. The manager must ensure that staffing levels form part of the Quality Assurance to ensure the needs of the people at the home met, particularly as staff have combined roles of cooking and caring. St Davids Lodge DS0000026625.V337521.R01.S.doc Version 5.2 Page 22 Two individuals living at the home were consulted about the staff and both said that the staff are good. Ten “Have your say” survey states that the staff are always available when they need them. There are fifteen staff currently employed at the home and documentation indicates that six people have NVQ level 2. The service provider stated that in future all staff will have access to vocational qualification. One member of staff stated that they had recently registered onto NVQ level 2. Since the last inspection five support workers were employed at the home. Completed application forms, two references and certificates are held within their personnel records. A current photograph of the person must be appended onto the records. A separate file is kept for Criminal Records Bureau (CRB) checks obtained for the staff employed at the home, which confirms that there is a robust recruitment process. The manager must discuss the convictions with the person the reasons for not disclosing the conviction in the application form. Also a current photograph of the member of staff must be kept in their personal record. There is a training programme in place and indicates that training is provided each month and is based on maintaining the standards of care at the home. The manager said that the training provided at the home is in-house through a training package. While in-house training is regularly provided, the trainer must be competent to deliver the training. Since the last inspection all staff have attended Infection Control, supervision, Dementia Awareness, First Aid and the role of the keyworker. New staff have undertaken induction to Skills for Care standards. St Davids Lodge DS0000026625.V337521.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The people living at the home can expect to live in a safe environment and can be re-assured that standards will be the subject of ongoing monitoring. EVIDENCE: The manager was consulted about the day-to-day management of the home. It was stated by the manager that the role of the manager is to instil enthusiasm about the work undertaken by support worker. This is to be achieved through a framework of staff meetings, supervision and Quality Assurance to increase empowerment for people living at the home. The St Davids Lodge DS0000026625.V337521.R01.S.doc Version 5.2 Page 24 manager stated that individual supervision occurs every eight weeks and the purpose is to provide staff opportunities to discuss issues, ensure staff understand their role and personal development. Supervision also focuses on praising work performance and undertaking appraisal. Three members of staff were consulted and they confirmed that supervision takes place. It was further stated by the staff that staff meetings take place monthly to ensure consistency of care. It was also stated that since the managers’ appointment, the care plans are clearer and there are opportunities for individual to go on holiday and more meaningful activities are organised. The two individuals giving feedback new the name of the manager and confirmed that the manager would be approached with concerns. The service provider convenes and attends monthly senior management meetings with the manager and senior staff to ensure the home operates within good practice. Copies of the reports indicate that an agenda is set and staff sign the report to evidence their agreement with the plan of action. The service provider should consider including the range of records examined during the visit to fulfil Regulation 26. A “Have your say” survey from the Community Learning Disability team (CLDT) state that the service could improve with “wider awareness of role’s of CLDT’s”. The manager stated that since then, the home’s questionnaires were used and professionals from the CLD team have indicated that there is better communication. The manager explained the Quality Assurance system in place. The views of the people living at the home, staff employed at the home, professionals and visitors are sought through questionnaires. The manager accepted that a quality cycle needs to be introduced to make the process meaningful and will be introduced alongside the Annual Quality Assurance Assessment (AQAA). Fees range from £46347-£850.00 per week. A record of fees charged at the home is maintained and included are the sources that contribute towards the fees. A record of cash held in safekeeping on behalf of the people living at the home is maintained. The record lists the date, nature of the transaction, running balance with the signature of the person. The cash held in safekeeping was checked against the records and found to be accurate and up to date. Since the last inspection, staff have attended in-house First Aid, Infection Control and Manual Handling Training. Food Hygiene training is scheduled for July and Health and Safety training to maintain staff’s skills and awareness. The records that relate to Health and Safety checks were examined. Fire risk assessments were undertaken to satisfy the Regulatory Reform (Fire Safety) Order 2005 in March 2006 by the service provider and reviewed by the manager. Other checks undertaken to maintain a safe environment for the St Davids Lodge DS0000026625.V337521.R01.S.doc Version 5.2 Page 25 people that use the service include annual checks of the heating system and portable equipment. Annual checks of the lift, bath hoist, stand aid and nurse call are also undertaken to provide a safe environment for the individuals at the home. An accident book is maintained by the home. St Davids Lodge DS0000026625.V337521.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x 3 x x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 x x 3 St Davids Lodge DS0000026625.V337521.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Yes 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 OP7 Regulation 15 Timescale for action Unless it is impracticable to carry 30/08/07 out such consultation, the registered person shall, after consultation with the service user, or a representative of his, prepare a written plan (the service users plan) as to how the service users needs in respect of his health and welfare are to be met. For individuals to receive a consistent service, care plans must be more detailed. 2. OP10 12(4) The registered person shall make 30/07/07 suitable arrangements to ensure that the care home is conducted - (a) in a manner which respects the privacy and dignity of service users; To maintain the dignity of the people at the home, the manager must ensure that personal care is undertaken by the individual takes place in private St Davids Lodge DS0000026625.V337521.R01.S.doc Version 5.2 Page 28 Requirement 3 OP9 12 (2) The registered person shall make 30/08/07 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. Individual medication profiles must be developed and must list the name of the medication, its purpose and the side effects. The registered person shall make 30/07/07 arrangements, by training staff or by other measures, to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. Policies and procedures must be clear about the way aggressive and violent behaviour is addressed at the home. Members of staff must have the skills to manage potentially aggressive situations and care plans must be clear about the way situations are consistently managed by the staff. The premises to be used as the care home are of sound construction and kept in a good state of repair externally and internally. The external space to the repair of the property requires attention and feedback from the individuals must be sought about what would best suit them. Subject to paragraphs (4 A), (6) (8) and (9), full and satisfactory information is available in relation to him in respect of the following matters(i) each of the matters specified in paragraphs. DS0000026625.V337521.R01.S.doc 4 OP18 12 (6) 5 OP19 23 (2) (b) 30/09/07 6 OP29 5 (d) (i) 30/07/07 St Davids Lodge Version 5.2 Page 29 7 OP33 24 The manager must ensure that the member of staff with convictions is suitable to work with vulnerable adults. The registered person shall establish and maintain a system for evaluating the quality of the services provided at the care home. A Quality Assurance cycle that measures the success of the aims and objective of the home must be introduces. 30/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations Consideration must be given to using a format that can be understood by the person. St Davids Lodge DS0000026625.V337521.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Davids Lodge DS0000026625.V337521.R01.S.doc Version 5.2 Page 31 - 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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