Inspection on 04/05/07 for Stanage Lodge Care Home

This inspection was carried out on 4th May 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Stanage Lodge Care Home 12/01/06

Stanage Lodge Care Home 13/09/05

Stanage Lodge Care Home 01/02/05

Stanage Lodge Care Home 12/08/04

Stanage Lodge Care Home 01/03/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 Stanage Lodge Care Home Milton Road Grimsby North East Lincs DN33 1AX Lead Inspector Rob Padwick Unannounced Key Inspection 4th May 2007 2:00 Stanage Lodge Care Home DS0000002812.V308595.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 Stanage Lodge Care Home DS0000002812.V308595.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. Stanage Lodge Care Home DS0000002812.V308595.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Stanage Lodge Care Home Address Milton Road Grimsby North East Lincs DN33 1AX 01472 230030 01472 230029 manager.stanagelodge@hica-uk.com 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) Humberside Independent Care Association Limited Julia Dawn Abram Care Home 20 Category(ies) of Learning disability (20), Learning disability over registration, with number 65 years of age (20) of places Stanage Lodge Care Home DS0000002812.V308595.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th January 2006 Brief Description of the Service: Stanage Lodge is registered to provide residential care for up to 20 younger adults with learning disabilities. There is division of places between long term and short term/respite service users. Respite care is generally offered to a relatively stable group of people. The home is a two-storey building and access to the second floor is via a passenger lift and stairs. The home has the benefit of good public transport routes. Stanage Lodge is owned and operated by Humberside Independent Care Association which is a ‘not for profit’ organisation. The standard fees charged by the home is £447.47, with additional charges made for specialist needs and for hairdressing, chiropody, toiletries etc. Stanage Lodge provides information to residents about its facilities in its Statement of Purpose and Service User Guide. Stanage Lodge Care Home DS0000002812.V308595.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A Pre Inspection Questionnaire asking for information about the home was sent to the manager before this visit and information from this was included as part of the inspection process. Other information used included reports from monthly visits carried out by a senior manager from the parent company and notifications received by the Commission for Social Care Inspection about serious incidents that had taken place in the home. Questionnaires were sent out to people living in the home and their relatives, together with professional staff that know the service well. Comments received from health staff were generally positive and the one relative questionnaire that was returned was also encouraging. Due to difficulties in completing the forms sent to them, staff had assisted the people living in the home to complete these, and those that were returned were also largely positive. Two inspection visits were made for this service, as the staff recruitment files were not available to be checked on the first visit. The main inspection visit to the home lasted for 5 hours and during this period, time was spent talking with people living in the home and observing their daily lives. Other time was spent looking at their care plans and other records and talking to staff. The inspection visit also included a tour of the building. What the service does well: What has improved since the last inspection? The manager and staff have continued to ensure that the views of people using the service are listened to and that they are involved in making decisions about the home and their lives. Stanage Lodge Care Home DS0000002812.V308595.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. Stanage Lodge Care Home DS0000002812.V308595.R01.S.doc Version 5.2 Page 7 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 Stanage Lodge Care Home DS0000002812.V308595.R01.S.doc Version 5.2 Page 8 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 4 People who use this service experience good, outcomes in this area. People living in the home had been provided with information about the home to help them make an informed choice about it and the manager had involved them and their representatives in the assessment process of their needs, in order to ensure that she could reach a decision that the service was able to meet these appropriately. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information had been developed about the home to help those thinking about moving in, make an informed choice about it. The files of the three people living in the home were inspected and all contained Local Authority assessments of their needs, which had been obtained before the individuals had been admitted to the home, in order to ensure that the service was able to meet them. A relative who was visiting stated that Stanage Lodge staff had been very supportive towards her family, in the process of reintroducing a family member back to the service for respite stays and confirmed that this process had involved a series of visits and stops for meals, to ensure that it was satisfactory for them. All of the case files contained copies of further assessments that had been carried out by staff in the home. These were of good quality and were person centred in nature, covering a wide range of the individual’s strengths and needs. These assessments were in a pictorial form Stanage Lodge Care Home DS0000002812.V308595.R01.S.doc Version 5.2 Page 9 with pictures and words to help the individuals understand them and evidence was seen that they and their relatives and representatives had contributed to this process of their development. Stanage Lodge Care Home DS0000002812.V308595.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 People who use this service experience good outcomes in this area. People living in the home were assisted to make choices and decisions about their lives and they were supported to take risks as part of an everyday life. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Observation of the care practices and discussion with people living in the home indicated that staff assisted them to make decisions and choices about their lives. Support plans covering a wide range of health and social needs were contained in each of the three case files that were inspected and these gave clear information to staff about how these were to be met. The Support plans were person centred in nature and developed in a format of words and pictures, to those living in the home understand them. Evidence was seen that individual’s had been involved in the development of their support plans and daily recordings were included within the case files inspected, which documented what they had done and how they had been. Some daily recordings were better than others however, and a recommendation is made that the standard of these be improved, in order to provide a clearer picture of Stanage Lodge Care Home DS0000002812.V308595.R01.S.doc Version 5.2 Page 11 the mood and behaviour. Evidence was seen that the support plans were being reviewed and updated regularly and staff were observed to have positive relationships with the people living in the home. Discussion with one staff member confirmed that this process was assisted by the home’s the “key worker” process, so that those living in the home had a particular staff member who was responsible for helping them to meet their individual needs. Behaviour management plans and issues concerning risk to the people living in the home were included within the case files that were inspected and staff indicated that these were based on a framework that was consistent with individual choice and part of their every day lives. The people living at Stannage Lodge have a wide range of needs and abilities and many have lived there for a number of years, whilst others visit as part of a programme of regular short respite stays. At the time of this visit a number of individuals were living in the home on an interim basis, following a breakdown of their previous living arrangements and discussion with staff indicated some uncertainty about long term plans for the future for these people, owing to a lack of appropriate accommodation elsewhere in the community. Owing to this factor and the consequent potential pressure on the service, the manager was reminded of the importance of robust admission and assessment procedures and the potential risk of admitting people into the service on the basis of limited information. Whilst there was is no suggestion made or evidence to indicate otherwise on this issue, a recommendation is made that in order to protect the people living in the home the home’s admission assessment incorporates a specific question relating to any safeguarding concerns that are known. Staff confirmed that they had been provided with a variety of training to help them do their jobs. However, a comment card returned from a professional member of staff in the community indicated that some further training was needed and inspection of the home’s training records highlighted gaps relating to this. A requirement is made in these matters (See Staffing) in order to ensure that staff have the necessary skills needed to meet the needs of the people living in the home. Stanage Lodge Care Home DS0000002812.V308595.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 People who use this service experience good outcomes in this area. People living in the home were supported by staff to make choices and be involved in decisions concerning their lives. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The case files inspected contained information relating to a variety of activities that were regularly undertaken by people living in the home. Those spoken with said they “liked going out” and information provided by the home’s manager indicated that these included attendance at various day centres, adult education classes and visits to clubs etc. The activities diary provided evidence of a number trips that had recently occurred including visits to the cinema, theatre, an ice show and a circus that had recently visited the town. On the evening of this inspection visit, one of the people living in the home went out to the pub with his key worker. Stanage Lodge Care Home DS0000002812.V308595.R01.S.doc Version 5.2 Page 13 Staff demonstrated a respect and understanding for the people living in the home and all those spoken with said that staff treated them well. Some people living in the home were observed enjoying the company of others watching TV, whilst others chose to stay in their own rooms and maintain their own privacy. Staff indicated that they tried to involve people living in the home to participate in a variety of things that were dependent on individual choice and needs and the availability of staff. The support plans that were inspected and the minutes of residents’ meetings contained further evidence that people living in the home were involved in decisions affecting their lives. The home has a visiting policy and works hard to work with the families of the people using the service and living at Stannage Lodge. The manager has developed a carers group for relatives and evidence was seen of regular meetings with them, in order to ensure that they are involved in decisions concerning the home. The one relative comment card that was returned as part of the inspection process indicated satisfaction with the service and stated “it takes good care of the needs of xx very well”. One visiting relative spoke positively about the sensitive support that had been shown in reintroducing a relative of hers back into the service and confirmed that this had been done very well. Care plans that were inspected contained evidence that people living in the home had been appropriately assessed concerning their nutritional needs and the records of food provided, together with the home’s menu’s confirmed that healthy options were always available. Some of those living in the home were observed to enjoy a main evening meal of meat stew and vegetables, whilst others had spaghetti bolognaise. People said that the food was good and the minutes from residents’ meetings confirmed that people living in the home had helped choose what was to be served. Stanage Lodge Care Home DS0000002812.V308595.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 People who use this service experience good outcomes in this area. The health and personal care needs of the people living in the home were being met by staff that had received training in how to meet these appropriately. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People living in the home indicated that staff were supporting their personal and healthcare needs satisfactorily and case files inspected provided evidence of staff actions concerning these matters. The three support plans inspected contained information relating to the personal care needs of the individual’s concerned, together with staff guidance on how these were to be met. Discussion with professional staff in the community confirmed that the staff in the home worked well with them whilst a Community Nurse Manager stated that the home’s staff obtained professional assistance and support appropriately and that the manager worked closely with her team. Similar feedback was obtained from a psychologist based at the local hospital. Good quality health action plans concerning the medical needs of the people living in the home were contained in the case files that were inspected and evidence was seen that that these were being monitored well. Medication Stanage Lodge Care Home DS0000002812.V308595.R01.S.doc Version 5.2 Page 15 policies and procedures were available to guide staff and ensure that people living in the home were protected in relation to this aspect of practice. Inspection of the home’s training records confirmed that those responsible for this aspect of practice had received relevant training on the safe use and handling of medication and a random check of home’s medication and associated records confirmed that these were being satisfactorily maintained. Owing to the numbers of people with diabetes living in the home, a recommendation is made that training relating to this aspect of practice is developed, in order that staff have the right skills and knowledge regarding this issue and to ensure that the medical needs of people living in the home are better met. Stanage Lodge Care Home DS0000002812.V308595.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People who use this service experience adequate outcomes in this area. The concerns of people using the service were being taken seriously and staff had received training concerning the protection of vulnerable adults. However, adult protection procedures needed following better, to make sure that people living in the home were properly safeguarded from harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Discussion with the people living in the home indicated that they were happy and that they would let staff know if they had any concerns. The home had a complaints policy which had been developed into an “easy read” format with pictures and words to make it easier for the people living at Stannage Lodge to understand it. The minutes of meetings with both people living in the home and their relatives, contained evidence that the manager took concerns about the service seriously and further evidence of this was seen in quality assurance systems for the home, which included a recent analysis of complaints received, together with action plans that had been developed from these. The one comment card returned from a relative as part of the inspection of this service indicated that the sender was satisfied with the home and was aware of how to make a complaint about it, if this was needed. Policies and procedures were available concerning the protection of vulnerable adults and discussion with staff indicated they were aware of these and would take appropriate action if this were needed. The training record for the home provided confirmation that staff had received training on this aspect of practice, which is included as an element of the staff induction process. Information supplied by the manager indicated that all of the people living Stanage Lodge Care Home DS0000002812.V308595.R01.S.doc Version 5.2 Page 17 permanently in the home had their own individual building society account and this was confirmed in discussion with the most senior member of staff on duty. A random inspection of the home’s records in relation to these, indicated that they were accurately maintained and that robust systems were in place, in order to ensure that the financial interests of people living in the home were being safeguarded. A serious incident had recently placed people living in the home at risk following an aggressive episode involving one of the people living in the home. Whilst risk assessments and a behaviour management plan were in place regarding this issue and subsequent action had been taken to involve Social Services, this matter should have been referred to the Local Authority under its duties to Safeguard vulnerable adults, as a matter of course. A requirement is therefore made regarding this issue, in order to ensure that those living and working in the home are properly protected. Stanage Lodge Care Home DS0000002812.V308595.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 People who use this service experience good outcomes in this area. The home was safe and generally well maintained, but some further redecoration would improve the environment for people living in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home was clean and generally well maintained, although some parts of the building were beginning to show signs of use and in need of upgrading and improvement. The home was built some time ago with bedrooms situated on two floors and access to them via a lift and corridor. People living in the home on a permanent basis have their own bedrooms and these were decorated to reflect their individual needs and wishes. However, a number of bedrooms used mainly for people staying for respite visits needed redecoration, to make them more homely, and a recommendation is made in this respect. One of the three bedrooms that are shared is used for people receiving a respite service and a concern was raised regarding the appropriateness of this. Staff confirmed that most of the people receiving Stanage Lodge Care Home DS0000002812.V308595.R01.S.doc Version 5.2 Page 19 respite are well known and have visited the home for considerable periods of time. Staff confirmed that agreement from individuals sharing the double room is obtained and that they are assessed for compatibility, however a recommendation is made regarding this matter, in order to ensure that their privacy and dignity is respected. A previous recommendation was made that people using the service on an emergency, short term or respite basis have separate accommodation and living arrangements to those living on a permanent basis in the home, and confirmation was obtained that discussions were currently underway with the service commissioners in respect of these matters. The home’s laundry facilities were clean and tidy and evidence was seen that work had been started to implement the requirements of the Local Authority Environmental Health Department concerning repairs needed to the kitchen floor. Stanage Lodge Care Home DS0000002812.V308595.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 People who use this service experience good outcomes in this area. A programme of training was in place to ensure that staff had the skills and abilities to do their jobs, but this needed to be further developed to ensure that needs of all of the people living in the home were met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Discussion with those working in the home and observation during this inspection visit indicated that people living at Stannage Lodge were being supported by staff that were committed to meeting their needs. The provider organisation has developed a comprehensive programme of induction and mandatory training and new staff confirmed that they were undertaking Learning Disability Award Framework (LDAF) training as part of this. A number of staff had left the service since the last inspection and whilst those on duty confirmed that they had attended courses on a good range of topics relevant for their work, examination of the training records indicated that this needed to be developed and targeted better, to ensure that staff are equipped with the skills needed to meet the needs of those living at Stannage Lodge. An incident had recently highlighted the need for staff to be trained in the management of challenging behaviour, and whilst day staff had received in this, the home’s Stanage Lodge Care Home DS0000002812.V308595.R01.S.doc Version 5.2 Page 21 training log indicated this was still needed for night staff. Other gaps relating to mandatory training in infection control were identified and despite previous recommendations that 50 of the staff attain an NVQ 2, information submitted by the manager indicated that only 21 of them had achieved this level of qualification. Requirements and recommendations are made in these matters. Two care staff and a senior member of staff were on duty at the time of this visit and inspection of the rota indicated that similar arrangements were in place at other times. Staff confirmed that additional support was usually brought in to help with busy periods and special activities that took place, but that sometimes this proved difficult to arrange. Discussion with the manager about this issue indicated that two new staff members had recently been recruited to help with this. The home had a recruitment policy and procedure in place to ensure that staff are safe to work with the people living in the home. However, information provided by the manager as part of the inspection process, indicated that a significant number of new staff members had begun employment with the parent organisation before their Criminal Records Bureau (CRB) checks had been received. As the staff files were not available on the first inspection visit, a second visit was made to inspect these. Evidence was seen that “POVA First” checks had been received for all of the relevant staff before they had started work, and inspection of their files confirmed that Criminal Records Bureau checks together with references and other required documentation had subsequently been obtained. The home’s manager stated that the new employees had not worked unsupervised in the home until after their CRB checks had been received and evidence of this was seen from inspection of the home’s rota. Whilst the practice of employing new staff, subject to “POVA First” checks being received is acceptable in exceptional circumstances, the manager was strongly reminded that this should not be carried out as a general rule. A recommendation is made about this. Stanage Lodge Care Home DS0000002812.V308595.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 People who use this service experience good outcomes in this area. The home was generally being well managed, but improved staff training and development of alternative respite provision locally would meet the needs of those using the service better. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager is qualified to manage the home and has previous experience of working in Learning Disability services in residential, respite and supported living settings. The minutes of meetings held in the home with both people living at Stannage Lodge and those using the respite care service, together with their carers and representatives provided evidence of consultation with them, in order that they could have some influence over the provision of the service. Both the home’s manager and other senior managers in the local authority confirmed that discussions were currently underway to improve the Stanage Lodge Care Home DS0000002812.V308595.R01.S.doc Version 5.2 Page 23 provision of alternative respite care services in the area. However, due to the different needs of people using the service, the dual role of combining both a permanent home for people living at Stannage Lodge as well as a respite care service is not an ideal one, and one that needs to be managed very carefully. A recommendation is made in this matter. A Community Nurse Manager who was approached confirmed that the staff at Stannage Lodge worked closely with members of her team in this respect and stated that the home’s manager was “open and honest in her approach” and that she said no to referrals for individuals whose needs she believed the home was unable to meet. Quality assurance systems were in place to monitor the effectiveness of the service and inspection of these indicated the manager had involved the people using the service and those living in the home, so that that they could participate in decisions concerning the home. A recent analysis of complaints received by the service had been carried out by the manager and evidence was seen of actions taken in relation to these matters. One complaint however had focussed on issues concerning the provision of hot water in the home and although evidence was seen that an engineer had been called out to resolve this, other documentation indicated that the home’s boiler system had not been serviced since October 2005, despite the provider organisation’s maintenance department being aware of this. A recommendation is made in this matter. Similarly, an analysis of questionnaires returned from people living in the home highlighted the need for some of the bedrooms and parts of the home to be redecorated and made more homely. Further recommendations are made. (See Environment) Information provided by the manager confirmed that a range of health and safety checks were being carried out to ensure the welfare of those living and working in the home were being protected. Inspection of the associated records for these confirmed that aspects relating to safety were being regularly discussed and evidence was seen of recent fire drills that had taken place in the home. However, as highlighted elsewhere in this report, aspects relating to staff training (See staffing) needed further development, in order to ensure that the needs of both those living at Stannage Lodge on a permanent basis and those staying at the home on a respite care basis and are met at all times. Stanage Lodge Care Home DS0000002812.V308595.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 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 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 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 3 13 3 14 X 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Stanage Lodge Care Home DS0000002812.V308595.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? N/A 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 YA23YA23 Regulation 13(6) Requirement The registered person must ensure that all incidents involving the possible abuse of people living in the home are referred to the Local Authority for investigation under its responsibilities for safeguarding vulnerable adults, in order that they are protected from harm. The registered person must ensure that night staff receive training in the management of challenging behaviour, in order that that the welfare of people living in the home is safeguarded. Timescale for action 04/05/07 2 YA35YA35 18(1c) 04/07/07 Stanage Lodge Care Home DS0000002812.V308595.R01.S.doc Version 5.2 Page 26 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 2 Refer to Standard YA6YA6 YA8YA8 Good Practice Recommendations The registered person should ensure that the daily recording relating to people living in the home is improved to indicate a clearer picture of their mood and behaviour. The registered person should ensure that the home’s admission assessment incorporates a specific question relating to any known safeguarding concerns about people referred to the service, in order to protect the people living in the home. The registered person should ensure that work is implemented to upgrade the bedrooms that are in need of redecoration and attention should be taken to improve the appearance of the building and make it more homely. The registered person should ensure that the practice of allowing staff checked against the Protection of Vulnerable Adults (“POVA First”) list are only in exceptional circumstances permitted to work in the home before a satisfactory Criminal records bureau check is received for them. The registered person should ensure that a training needs assessment and development plan is developed that is based on the needs of the staff and people using in the home. The registered person should continue exploring the development of alternative respite provision with the services commissioner, in order to enhance the quality of service to the people living permanently in the home. The registered person should ensure that the homes boiler system is serviced at appropriate intervals. 3 YA24YA24 4 YA34YA34 5 YA35YA35 6 YA37YA37 7 YA42YA42 Stanage Lodge Care Home DS0000002812.V308595.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Stanage Lodge Care Home DS0000002812.V308595.R01.S.doc Version 5.2 Page 28 - 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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