Inspection on 28/02/07 for St Michael`s Lodge

This inspection was carried out on 28th February 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Michael`s Lodge 25/02/09

St Michael`s Lodge 28/02/06

St Michael`s Lodge 02/03/05

St Michael`s Lodge 19/04/04

St Michael`s Lodge 09/01/04

Similar services:

Trevayler Residential Care Home

Thornham Grove

Thistle Hill Hall

Conifer Lodge

Westwood Lodge

Egerton Lodge Care Home

Alfred Minto House Care Home

St Matthews Unit

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

CARE HOME MIXED CATEGORY MAJORITY ADULTS 18-65 St Michael`s Lodge 6-8 St Michael`s Avenue Northampton Northants NN1 4JQ Lead Inspector Debbie Williams 28th February 2007 Site Visit 12:00 St Michael`s Lodge DS0000012926.V320079.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 St Michael`s Lodge DS0000012926.V320079.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 and 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. St Michael`s Lodge DS0000012926.V320079.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Michael`s Lodge Address 6-8 St Michael`s Avenue Northampton Northants NN1 4JQ 01604 250355 01604 638496 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) Mr Raymond Galbraith Mrs Anne Going, Mr Kenneth Going, Mrs Marian Galbriath Mr Raymond Galbraith Care Home 13 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (13) of places St Michael`s Lodge DS0000012926.V320079.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home may continue to provide care for 2 existing named service users under 45 years of age The Home provides care for Service Users in the Age category of 45yrs to 65yrs and 65yrs and over. 28th February 2006 Date of last inspection Brief Description of the Service: St Michaels Lodge is a care home providing care and accommodation for 13 service users with Mental Disorders excluding Learning Disabilities and Dementia. Mr K. and Mrs A. Going and Mr R. and Mrs M. Galbraith own the home. Mr R. Galbraith is the Registered Manager. The home is situated within easy access to the Tying Centre and adjacent to a local shopping centre. The home was opened in 1989 and consists of a large Victorian three-storey building providing three double bedrooms and seven single rooms. The home has a stair lift to the basement floor. There are two lounges and a dining room and service users have access to the rear garden St Michael`s Lodge DS0000012926.V320079.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a positive inspection. The main method of inspection used was ‘case tracking’ which involved selecting residents and tracking the care they receive through the checking of their records, discussion with them and observation of care practices. Good outcomes were achieved in all but one area. The service was judged as poor in one area. Residents spoken with were happy with the service provided. What the service does well: What has improved since the last inspection? There were no requirements or recommendations made at the last inspection. An ongoing training and development programme is in place for all care staff to ensure they are equipped with the skills required to meet residents’ needs. St Michael`s Lodge DS0000012926.V320079.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. St Michael`s Lodge DS0000012926.V320079.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) St Michael`s Lodge DS0000012926.V320079.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 1,2 and 4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents individual needs are assessed prior to them moving into the home. EVIDENCE: Resident’s needs are assessed prior to admission. The proprietor and home manager carry out all assessments. The majority of placements at the home are long-term placements. The last admission to the home was managed over a period of time, beginning with a visit then gradually increasing from overnight to weekend stays, this was managed to ensure the resident’s comfort and gain their confidence. A service users guide is provided to all prospective residents. Residents sign to say they have received this. St Michael`s Lodge DS0000012926.V320079.R01.S.doc Version 5.2 Page 9 St Michael`s Lodge DS0000012926.V320079.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14 and 33 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 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 provides appropriate levels of support based on the assessed needs of individual service users. EVIDENCE: Care records of three case tracked residents were inspected. Care plans and assessment records were comprehensive and included individual risk assessments. Residents spoken with felt they were enabled to take appropriate risks and make decisions. St Michael`s Lodge DS0000012926.V320079.R01.S.doc Version 5.2 Page 11 St Michael`s Lodge DS0000012926.V320079.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. 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. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. 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. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. 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. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers Standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 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. Daily routines were flexible and met the lifestyle needs and expectations of residents accommodated. St Michael`s Lodge DS0000012926.V320079.R01.S.doc Version 5.2 Page 13 EVIDENCE: At the time of this inspection two of home’s residents were attending day centres. Residents were able to leave the home to go for walks or to the shops etc as they wished. A sister home is situated across the road; residents from both homes are able to use facilities at either home. Activities are provided in both homes, on the day of this inspection residents were going across the road to make smoothies. Other activities on offer included arts and crafts and DVD nights. It was evident that staff enabled residents to maintain links with family and friends. Residents spoken with confirmed their visitors were made welcome. Interactions observed between staff and residents were very positive and respectful. Residents spoken with praised the staff and felt they were treated with respect and able to maintain their independence. Menu records were seen and appeared to provide a nutritious and varied diet. Residents spoken with were happy with the meals provided. St Michael`s Lodge DS0000012926.V320079.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) 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. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18,19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The personal and healthcare needs of residents are met. EVIDENCE: The level of personal support required by each resident was recorded in individual care plans. Residents spoken with felt they received appropriate personal support and staff maintained their privacy and dignity. The physical and emotional health needs of residents are assessed and recorded within care records. Records are maintained of GP and other healthcare professional contact and appointments. All care staff administer medication. Two staff sign for all medication. The proprietor assesses staff competency in this area. St Michael`s Lodge DS0000012926.V320079.R01.S.doc Version 5.2 Page 15 Medication charts are audited monthly when the order is placed. The majority of staff have attended a medication management course. Medication is supplied in blister packs. Medication storage and administration records seen and appeared in good order. St Michael`s Lodge DS0000012926.V320079.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16-18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 22-23 (Adults 18-65) and Standards 16-18 and 35 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Policies and procedures in place serve the best interests of residents and promote protection. EVIDENCE: Residents spoken with felt they would be happy to raise a complaint with the home manager or owners. Complaints procedures are given to all residents with the service users guide. Safeguarding adults training is provided to staff as part of their induction training. At the time of this inspection, staff were working through an internet learning (e learning) course regarding safeguarding adults provided by the local council. The management of challenging behaviour training is provided for staff. Records are maintained of all financial transactions regarding resident’s personal money. St Michael`s Lodge DS0000012926.V320079.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Resident’s quality of life would be enhanced if all areas of the home were decorated to a reasonable standard and all items of furniture were of good quality and in good condition, EVIDENCE: A tour of the premises was undertaken. The front door was found to have scratched paintwork and damaged woodwork so was in need of St Michael`s Lodge DS0000012926.V320079.R01.S.doc Version 5.2 Page 18 refurbishment/replacement. The manager said they were in the process of arranging a replacement and that a programme of redecoration was planned into next years budget. The corridors would also benefit from redecoration to bring them up to a reasonable standard. Furniture in the lounge is shabby with some of the chair arms ripped and stained and these need replacing. All areas of the home appeared clean and hygienic. Two case-tracked resident’s rooms were seen, both appeared homely and personalised. Maintenance work is carried out by the owners unless specialised work is required then outside contactors are sought. St Michael`s Lodge DS0000012926.V320079.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 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. Recruitment procedures protect residents and staff are trained to meet residents needs. EVIDENCE: At the time of this inspection there were ten residents accommodated in the home. The home was staffed with two staff during daytime hours, one waking night staff with other staff on call. There was separate domestic staff. Residents spoken with felt there were sufficient staff on duty to meet their needs. St Michael`s Lodge DS0000012926.V320079.R01.S.doc Version 5.2 Page 20 National Vocational Qualification training is in progress for staff. A new induction training pack was being introduced. The proprietor said there was a low staff turnover. Staff training records were seen. One staff member’s personnel file was seen and found to contain all relevant checks and references. St Michael`s Lodge DS0000012926.V320079.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. 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. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) 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 homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37,39 and 42. 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 run and the best interests of residents are promoted. St Michael`s Lodge DS0000012926.V320079.R01.S.doc Version 5.2 Page 22 EVIDENCE: The Registered Manager has extensive management experience and residents spoken with had every confidence in his ability to meet their needs. Regular residents and staff meetings are held. Resident’s satisfaction questionnaires are sent out annually. The home was recently awarded three roses as part of the local authority quality assurance assessment. All required health and safety training is provided to staff. The registered provider carries out risk assessments and these are done in conjunction with the quality audit. There are also personal risk assessments for each resident. St Michael`s Lodge DS0000012926.V320079.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. 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 x 4 3 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 1 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 Standard No Score 37 3 38 x 39 3 40 x 41 x 42 x 43 3 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 St Michael`s Lodge Score 3 3 3 x DS0000012926.V320079.R01.S.doc Version 5.2 Page 24 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 YA24 Regulation 23 (2)(b) (d) Requirement All areas of the home must be kept in a good state of repair and reasonably decorated. Timescale for action 30/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St Michael`s Lodge DS0000012926.V320079.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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 Michael`s Lodge DS0000012926.V320079.R01.S.doc Version 5.2 Page 26 - 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. 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