CARE HOME ADULTS 18-65
Stonesby Lodge 109 Stonesby Avenue Leicester Leicestershire LE2 6TY Lead Inspector
Martin Hefferman Key Unannounced Inspection 19th September 2007 09:45 Stonesby Lodge DS0000006370.V341460.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 Stonesby Lodge DS0000006370.V341460.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. Stonesby Lodge DS0000006370.V341460.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Stonesby Lodge Address 109 Stonesby Avenue Leicester Leicestershire LE2 6TY 0116 2830128/2701744 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) gbonom@dmu.ac.uk Mr R Bonomaully Mrs S Bates Care Home 12 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (12) of places Stonesby Lodge DS0000006370.V341460.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. No additional conditions of registration. Date of last inspection 25th July 2006 Brief Description of the Service: Stonesby Lodge provides a service for 12 people with mental health problems. The home, opened in 1989, is an extended detached house located on the edge of the Saffron Lodge estate. It has a large lounge-diner and a smaller lounge where staff and residents may smoke. The majority of residents rooms (7 single and 1 double) are located on the ground floor. There is one single and one double room located on the first floor. All rooms have wash hand basins and double rooms have appropriate screening. There are two bathrooms, one shower room and two additional toilets. The home has two internal courtyards, accessible to residents, which have been made more attractive with plants, paving and patio furniture. The home is situated on a main road, close to shops, churches, day services, the library and other amenities. There are regular bus services to Leicester and Wigston. Current fees at the home are approximately £297 per week. Stonesby Lodge DS0000006370.V341460.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. A visit to the home took place on 19th September 2007, lasting approximately four and three quarter hours. The main method of inspection used on that day was ‘case tracking’ which involved selecting three people who live at the home and tracking the care they receive through review of their records, discussion with them (where possible) & staff and observation of care practices. Four residents were spoken to during the course of the visit, including two of the three people who were chosen for the purposes of case tracking. The inspection also took account of all information received since the date of the last visit. The provider’s self-assessment form had not however been received at the time of writing this report. What the service does well: What has improved since the last inspection? What they could do better:
An up-to-date copy of the service user’s guide should be supplied to the Commission and every person who lives at the home to ensure that they have the information they require about the service they receive.
Stonesby Lodge DS0000006370.V341460.R01.S.doc Version 5.2 Page 6 An up-to-date assessment of a prospective resident’s needs should be obtained to enable the registered persons to decide whether the home is able to meet those needs. A written plan must be prepared for every resident so that they and staff know how their needs will be met. Individual plans and risk assessments must be kept under review to ensure that they reflect residents’ changing needs. Information about when residents should take ‘as required’ medication must be clearly documented to ensure consistency in administration. A system should be implemented to monitor when areas of the building need redecoration and when items of furniture, curtains or floor coverings need replacing. Residents should be actively involved in this process. The areas of the home that were identified at the time of the visit should be redecorated and floor coverings should be replaced. An assessment of the level of risk associated with the fact that windows are unrestricted should be formally recorded. Staff records must be available to verify that residents are protected by the home’s recruitment practices and their needs met by trained staff. Staff members should have access to training which develops their understanding of mental health to ensure that they continue to meet all present and future residents’ needs effectively. A method of measuring and ensuring quality in the home must be implemented to ensure that standards are maintained and improved. This system should include regular and ongoing consultation with residents, their relatives and other interested parties such as social workers and doctors. A record should be kept of any issues identified by the registered provider during his visits to the home. All staff members who prepare food should receive training in food hygiene and an up-to-date record of all fire tests must be maintained to demonstrate that the health & safety of residents is protected. 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. Stonesby Lodge DS0000006370.V341460.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 Stonesby Lodge DS0000006370.V341460.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 & 4 Quality in this outcome area is adequate. The admission process does not currently ensure that prospective residents have the information they require and that an up-to-date assessment of their needs is completed before a decision is taken that they should move in. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information about the service provided to residents was not available at the time of the visit. One person stated that she could not recall having received written information about the home when she moved in. The registered manager reported that a number of residents had lived at the home for many years and may have mislaid the documents given to them. Several people stated that they had been able to visit Stonesby Lodge and to stay overnight before deciding to move in. One of the people who were chosen for the purposes of case tracking moved to the home during April 2007. A copy of an assessment (dated April 2000) & a care plan completed by a social worker were available for inspection. Both of the documents related to the person’s need for support in the community. The registered manager stated that the person had been a regular visitor to the home & had been well known to her & care staff before she moved in. Stonesby Lodge DS0000006370.V341460.R01.S.doc Version 5.2 Page 9 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 & 9 Quality in this outcome area is adequate. Residents are encouraged to make decisions about how they spend their time. Working practices do not currently ensure that information about how staff members will meet residents’ needs is documented and kept under review. This judgement has been made using available evidence including a visit to this service. EVIDENCE: An up-to-date copy of an individual plan was available for one of the people who were chosen for the purposes of case tracking. Originally completed in May 2006, it had been reviewed during September 2007 and had been signed by the resident to indicate that they were in agreement. The individual plan for a second person did not appear to have been reviewed since August 2005. The registered manager stated that a plan had yet to be completed for a third resident who moved to the home during April 2007. She reported that staff members were working to an assessment & care plan completed by a social worker, both of which related to her need for support in the community. Individual risk assessments were available. Those that were inspected had not been reviewed since they were completed in 2004.
Stonesby Lodge DS0000006370.V341460.R01.S.doc Version 5.2 Page 10 People who live at the home stated that they are able to choose how they spend their free time. They reported that they are able to come and go as they please as long as they let staff members know that they are going out and what time they will be back. Several residents went for a walk during the course of the visit. Stonesby Lodge DS0000006370.V341460.R01.S.doc Version 5.2 Page 11 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 & 17 Quality in this outcome area is good. Residents are able to access appropriate community, leisure & vocational activities and are well supported in maintaining their personal relationships. They enjoy the meals that are provided. This judgement has been made using available evidence including a visit to this service. EVIDENCE: One of the people who were chosen for the purposes of case tracking stated that he enjoys weekly computer classes. Other residents attend local colleges, supported work schemes and other day services. Residents attend a number of local churches. One person received a visit from a representative of a local church during the course of the inspection. Two residents stated that they have Leicester City Football Club season tickets and regularly attend matches accompanied by the home’s owner. One person stated that she enjoys going to a local library. A number of residents were involved in making decorations for a Halloween party during the afternoon of the visit. Records indicate that residents are in regular contact with their families and friends where possible.
Stonesby Lodge DS0000006370.V341460.R01.S.doc Version 5.2 Page 12 Residents stated that they enjoy the meals that are provided. They reported that a choice of meals is always available. Records indicate that residents receive a varied diet. Stonesby Lodge DS0000006370.V341460.R01.S.doc Version 5.2 Page 13 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 & 20 Quality in this outcome area is adequate. Residents’ personal & healthcare needs appear to be met. Care planning practices must however be strengthened to ensure that information about how staff members will meet those needs is documented and kept under review. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents stated that they are happy with the support they receive. The individual plans that were inspected detailed the personal support each person requires. The plans also set out details of any healthcare needs that have been identified and of any action that is felt to be necessary as a result. A requirement has been made that individual plans must be prepared for every resident and that they must be kept under review to ensure that the information contained within them is up-to-date. Records of appointments attended by residents indicate that they have access to appropriate healthcare professionals. None of the people who were chosen for the purposes of case tracking managed their medication at the time of the visit. Records have been kept of all medicines received into the home, administered to residents and returned for disposal. The registered manager stated that protocols setting out the
Stonesby Lodge DS0000006370.V341460.R01.S.doc Version 5.2 Page 14 circumstances in which ‘as required’ medication should be administered had not been completed as required at the time of the last inspection. She reported that staff members have received medication training although no records were available to verify this (see Staffing). Stonesby Lodge DS0000006370.V341460.R01.S.doc Version 5.2 Page 15 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 & 23 Quality in this outcome area is good. Residents’ views are listened to and they are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents stated that they would speak to the manager or staff members if they had any concerns. A copy of the complaints procedure is displayed on the residents’ notice board in the lounge. The registered manager agreed to amend the procedure to reflect revised guidance from the Commission about the handling of complaints. She stated that no complaints had been received since the date of the last inspection. The registered manager has obtained a copy of the local multi-agency policy and procedures on the protection of vulnerable adults. She agreed to request a copy of the revised edition from Social Services. Staff members have received training on safeguarding adults as part of their National Vocational Qualifications. The registered manager stated that no money is held on behalf of residents and that no staff members have been recruited since the date of the last inspection. Stonesby Lodge DS0000006370.V341460.R01.S.doc Version 5.2 Page 16 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 & 30 Quality in this outcome area is adequate. Although there is evidence of improvement in some areas, other parts of the home remain in a poor state of repair and decoration. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A number of residents’ rooms, all communal areas and part of the grounds were inspected during the course of this visit. Residents stated that they were happy with their rooms, which were generally decorated to a satisfactory standard. The areas of the home that were inspected were clean and tidy. Since the date of the last inspection, new windows have been fitted in four rooms; two bedrooms have been redecorated and a step has been installed in a downstairs shower room. Some of these jobs were in the process of being finished off at the time of the visit. The following issues were identified that require attention: the floor coverings in an upstairs bathroom & a downstairs toilet needed to be replaced; another bathroom smelt damp; a number of windows were rotten; and several bedrooms needed to be redecorated. The registered manager stated that windows had been ordered for four more rooms and that these rooms would be redecorated as soon as the windows
Stonesby Lodge DS0000006370.V341460.R01.S.doc Version 5.2 Page 17 were fitted. She reported that a system had not been put in place for ensuring that the physical environment of the building is improved and that the improvement is maintained as recommended at the time of the last inspection. It was noted that windows in upstairs rooms have not been fitted with restrictors. The registered manager stated that she did not feel that any of the residents were at risk as a result. She was reminded that fire doors must not be wedged open. Stonesby Lodge DS0000006370.V341460.R01.S.doc Version 5.2 Page 18 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 & 35 Quality in this outcome area is poor. Staff records were not available to verify that residents are protected by the home’s recruitment practices and that their needs are met by trained staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents appeared to enjoy a positive relationship with the staff on duty at the time of the visit. A number of them stated that there are enough staff on duty and that they are well looked after. The roster for the week in which the visit took place indicated that there were two members of staff on duty during the day and one at night. Records relating to staff recruitment and training were not available at the time of the visit. The registered manager stated that no staff had been recruited since the date of the last inspection. She reported that five members of staff had completed National Vocational Qualification levels 2 or 3 and that two members of staff were in the process of completing such an award. Staff members have not received training on mental health or food hygiene as recommended at the time of the last inspection. Stonesby Lodge DS0000006370.V341460.R01.S.doc Version 5.2 Page 19 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 & 42 Quality in this outcome area is adequate. Residents are satisfied with the overall running of the home. There is however no system in place for monitoring the quality of the service provided to ensure that standards in all areas are maintained and improved. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager stated that she has yet to start her Registered Manager’s Award (RMA) but is hoping to do so as soon as funding becomes available. She has several years experience of working with adults with mental health problems. She stated that she continues to attend conferences to update her knowledge in various areas. A quality assurance system has been purchased since the date of the last inspection but has yet to be implemented as recommended at that time. The roster indicates that the owner visits the home most evenings. No records were available of any issues identified by him during those visits.
Stonesby Lodge DS0000006370.V341460.R01.S.doc Version 5.2 Page 20 Records indicate that the fire alarm system has been tested on a weekly basis. The last entry in records for fire drills and the home’s tests of the emergency lighting system were dated May & June 2006 respectively. The emergency lighting system had however been serviced by an outside contractor during July 2007. Residents confirmed that fire drills took place on a regular basis. Electrical appliances were tested in January 2007. The registered manager stated that two members of staff (including herself) had updated their qualifications in first aid & food hygiene but had yet to receive their certificates. She reported that some of the staff who were responsible for preparing food had yet to receive training in food hygiene as recommended at the time of the last inspection. Stonesby Lodge DS0000006370.V341460.R01.S.doc Version 5.2 Page 21 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 2 2 2 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 1 35 1 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 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 Score 2 2 2 X 3 X 2 X X 2 X Stonesby Lodge DS0000006370.V341460.R01.S.doc Version 5.2 Page 22 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 YA6 Regulation 15 Requirement A written plan must be prepared for every resident so that they and staff know how their needs will be met. Individual plans and risk assessments must be kept under review to ensure that they reflect residents’ changing needs. Information about when certain residents should take ‘as required’ medication must be clearly documented to ensure consistency in administration. The previous timescale of 04/08/06 was not met. Staff records must be available to verify that residents are protected by the home’s recruitment practices and their needs met by trained staff. A method of measuring and ensuring quality in the home must be implemented to ensure that standards are maintained and improved. An up-to-date record of all fire tests must be maintained to demonstrate that residents are protected.
DS0000006370.V341460.R01.S.doc Timescale for action 31/10/07 2. YA6 15 30/11/07 3. YA20 13 31/10/07 4. YA34 YA35 19 17/10/07 5. YA39 24 31/12/07 6. YA42 17 19/09/07 Stonesby Lodge Version 5.2 Page 23 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 YA1 Good Practice Recommendations An up-to-date copy of the service user’s guide should be supplied to the Commission and every person who lives at the home to ensure that they have the information they require about the service they receive. An up-to-date assessment of a prospective resident’s needs should be obtained to enable the registered persons to decide whether the home is able to meet those needs. A system should be implemented to monitor when areas of the building need redecoration and when items of furniture, curtains or floor coverings need replacing. Residents should be actively involved in this process. The areas of the home that were identified at the time of the visit should be redecorated and floor coverings should be replaced. An assessment of the level of risk associated with the fact that windows are unrestricted should be formally recorded. Staff members should have access to training which develops their understanding of mental health to ensure that they continue to meet all present and future residents’ needs effectively. A record should be kept of any issues identified by the registered provider during his visits to the home. All staff members who prepare food should receive training in food hygiene to ensure that the health and safety of residents is protected. 2. 3. YA2 YA24 4. 5. 6. YA24 YA24 YA35 7. 8. YA39 YA42 Stonesby Lodge DS0000006370.V341460.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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
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