Inspection on 13/09/05 for SummerLodge

This inspection was carried out on 13th September 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

SummerLodge 15/12/08

SummerLodge 07/12/06

SummerLodge 28/02/06

SummerLodge 07/02/05

SummerLodge 28/10/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Summerlodge 20 Grosvenor Road Westcliff-on-Sea Essex SS0 8EN Lead Inspector Helen Laker Unannounced Wednesday 13 September 2005 th 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 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 Stationary 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. Summerlodge I56 S49088 Summerlodge V233910 130905 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Summerlodge Address 20 Grosvenor Road Westcliff-on-Sea Essex SS0 8EN 01702 343139 01702 343139 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Summer Care Homes Ltd Ms Sheena Fleming CRH Care Homes 5 Category(ies) of LD Learning Disability (5) registration, with number of places Summerlodge I56 S49088 Summerlodge V233910 130905 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Personal care to be providedto 5 residents with a learning disability. 2. Maximun number to be cared for 5 (five). 3. The age of the service users will be between 18 and 65 years. Date of last inspection 7th February 2005 Brief Description of the Service: Summer Lodge presents as a family style premises in a residential area of Westcliff. It is within walking distance of the seafront and local shops and bus and train routes are easily accessible. There is some parking on the front driveway. The home is registered to accommodate 5 people with learning disabilities. There are 4 single rooms on the upper floor and one on the ground floor. A separate lounge, dining room and a music room are also available. Limited parking is available to the front of the property. Summerlodge I56 S49088 Summerlodge V233910 130905 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine, unannounced inspection which took place over five hours with two inspectors in the home one of whom was observing. There was a tour of the premises and grounds and an inspection of records and documentation. Time was spent discussing the care of the five service users. Three members of staff were spoken with. Twenty eight National Minimum Standards were inspected on this occasion, fifteen overall outcomes were met and there were ten requirements and three recommendations detailed in the full report. Discussion of the inspection findings took place with the deputy manager in charge at the end and throughout the inspection and guidance was given. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by Summerlodge I56 S49088 Summerlodge V233910 130905 Stage 4.doc Version 1.30 Page 6 contacting your local CSCI office. Summerlodge I56 S49088 Summerlodge V233910 130905 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Summerlodge I56 S49088 Summerlodge V233910 130905 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,5 The service users guide and contracts are still being developed. The admission procedure does include an adequate assessment which ensures that service users needs can be met. The home provides a caring environment where visitors are made welcome. EVIDENCE: A pictorial service users guide is still being developed. Detailed pre admission assessments of needs are carried out for each individual prior to being offered a placement at the home. Each service user is issued with a contract including terms and conditions of occupancy on admission to the home, these are being developed pictorially. The contract for the most recent admission was noted to be unsigned and undated It was noted at the last inspection and recommended that individual contracts include the arrangements for holidays where service users do not wish to take a seven day break from the home. Summerlodge I56 S49088 Summerlodge V233910 130905 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,9 Each service user has an individual plan, although not all contained all the information required. Service users are supported to take risks as part of an independent lifestyle via a process of assessment. Due to some service users’ learning disabilities they are only able to make limited decisions but staff facilitate this as much as possible. EVIDENCE: Care plans which focus upon activities of daily living and the development of practical life skills are implemented for individual service users. Care plans sampled had not been reviewed on a regular basis and in some cases omitted essential information regarding services users health and welfare. There was also no evidence of family consultation or involvement Service user involvement is limited due to the level of comprehension of the client group. It is recommended that service users understanding of the care planning is assessed and documented. Service users at the home are encouraged to make decisions wherever possible. Where limitations to choice have been imposed this had not been recorded, for example, with one service user who used a baby monitor. It is recommended as a matter of good practice that the individuals understanding of the risk and need for restrictions are included within these records. Service users at the Summerlodge I56 S49088 Summerlodge V233910 130905 Stage 4.doc Version 1.30 Page 10 home rely upon the intervention of staff to assess actual and potential risks to health, safety and welfare. Comprehensive risk assessments, which are reviewed according to level of assessed risk, were sampled. Those sampled had not been updated adequately. Summerlodge I56 S49088 Summerlodge V233910 130905 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,15,16,17 Social activities take place and service users are generally happy with the choices in routine available to them. Visitors are made welcome and overall the service users rights and responsibilities are recognised in their daily lives. EVIDENCE: Although no service users currently attend educational courses they do attend day centres and service users preferences in respect of education and training are recorded in the individual’s assessments. Service users are provided with information on opportunities available and are encouraged to take up education and training courses, which suit individual wishes and capabilities. They are also encouraged and supported where required in accessing local community amenities and to spend weekend time with family outside of the home. Service users are encouraged to meet people and form friendships. As far as possible service users can choose whom they wish / do not wish to see. At the time of this inspection service users did not have keys to their personal accommodation. It was recommended at the last inspection that the reason for this decision based upon assessment of capability and risk for each individual be recorded. Summerlodge I56 S49088 Summerlodge V233910 130905 Stage 4.doc Version 1.30 Page 12 Service users are observed for signs, which would indicate consent and staff act on this information to ensure that individual’s privacy and dignity is maintained. Where service users chose not to participate in an activity or wish to be alone this is recorded. Staff plan menus with input from service users. A community nurse and dietician are involved in the care management of one service user who has problems with swallowing however preferences for the presentation of their food was not recorded. Service users weights are recorded on a monthly basis unless it is otherwise indicated. Nutritional records are maintained for all service users, which demonstrate that service users receive a nutritionally balanced diet, which meets any specialist dietary needs and is available for inspection upon request. Summerlodge I56 S49088 Summerlodge V233910 130905 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19,20 Arrangements are in place to ensure that the health care needs of service users are identified and met. Minor omissions in medication administration were evident EVIDENCE: Personal care is provided in private in service users bedrooms or bathrooms according to individuals’ wishes. All service users resident at the home at the time of this inspection were fully mobile. Service users at the home depend on staff support in management of healthcare needs. A record of medical and other therapeutic appointments, which include outcomes are maintained for each service user. It was reported that service users at the home at the time of this inspection were not capable of safely administering their own medication. It is recommended that this be recorded as part of the risk assessment for each individual. Staff said that service users consent to medication is considered unless an individual refuses medication. It was recommended that this be recorded within the care notes. Protocols for the administration of ‘as required’ (PRN) medication were in place for each service user. Regular internal audits of medication records, administration and storage are carried out the results of Summerlodge I56 S49088 Summerlodge V233910 130905 Stage 4.doc Version 1.30 Page 14 which were not available for inspection and some administration omissions were noted. Summerlodge I56 S49088 Summerlodge V233910 130905 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22,23 The home has an appropriate complaints policy which informs complainants of their rights and assures them their complaint will be taken seriously. Staff are aware of the issues relating to the protection of vulnerable adults. EVIDENCE: There have been no complaints made to the CSCI since the last inspection and staff at the home said that there had been no complaints made to the home. The homes policy for dealing with complaints meets the National Minimum Standards. A log of complaints is maintained and available for inspection. The home has a clear policy for recognising and dealing with issues regarding protection of vulnerable adults. There were also available policies for dealing with difficult behaviour and aggression, which were detailed and easy to understand. Summerlodge I56 S49088 Summerlodge V233910 130905 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25,26,27,28,29,30 Summer Lodge was clean and bright and provided the service users with homely and comfortable surroundings. Improvements have been made to the home and other internal maintenance and decoration issues have management systems in place. EVIDENCE: The registered provider is developing a system of prioritising maintenance requirements, it is now noted on a job form. It was noted at the last inspection that there were various fixtures and fittings awaiting attention. The home was noted to be maintained to an acceptable standard in respect of hygiene. The front driveway has been tarmacced. Service users bedrooms seen were decorated and personalised according to the individuals taste. Most of the service users bedrooms are equipped with ensuite facilities, and toilet facilities meet the needs of service users. Summer Lodge had ample shared space available. Communal rooms were cosy and domestic in presentation. Standard 26 was not fully inspected during this inspection. This standard will be inspected at the next inspection. The upstairs bathroom has had frosted covering applied to the glass in the window to ensure service users privacy. Summerlodge I56 S49088 Summerlodge V233910 130905 Stage 4.doc Version 1.30 Page 17 Bathroom and toilet facilities at Summer Lodge meet the needs of service users. Service users have access to a small maintained garden area. The deputy manager said that no service user has a sensory or physical disability that requires specialist equipment, however appropriate equipment would be provided as required. A sensory room is currently being developed. The home has detailed policies and procedures in respect of infection control. Stored water checks for prevention of Legionella infection are carried out quarterly and appropriate records are maintained. Systems are in place for the handling of soiled laundry. Summerlodge I56 S49088 Summerlodge V233910 130905 Stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34,35 It was not possible to confirm that adequate recruitment policies and practices were in place on this occasion due to the disorganisation of records. The home has an effective and competent staff team who receive training to the required standard this was not up to date and could not be confirmed due to the absence of evidential records. EVIDENCE: Four staff files were inspected. The most recent person employed had no documentation at all, and the other’s had several major omissions. This was bought to the deputy manager’s and the company’s HR Department’s attention. Original CRB checks were not kept on the premises. Staff recruitment files sampled did not demonstrate that robust recruitment procedures are practiced. Service users are involved in the selection process wherever possible. A training plan has been implemented but was not available for inspection. The inspector was informed that plans are in place for Learning Disability Award Framework (LDAF) training for all care staff. Summerlodge I56 S49088 Summerlodge V233910 130905 Stage 4.doc Version 1.30 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,39,42 There is evidence of guidance and direction to staff and the home generally has in place practices that will promote and safeguard the health, safety and welfare of the people using the service. The legal aspects of this regarding documentation could not be ascertained. EVIDENCE: The acting manager has not yet applied for registration or undertaken NVQA level 4 in care and management. A quality monitoring system is being developed further to include the views of service users families and friends and other stakeholders. Work is ongoing within the home to comply with fire regulations and a number of safety certificates were also not available to inspect such as the electrical and gas certificates. The deputy manager was reminded that an up to date copy must be in the home and available for inspection. Summerlodge I56 S49088 Summerlodge V233910 130905 Stage 4.doc Version 1.30 Page 20 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 x x 2 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 2 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 x 3 3 x 2 3 2 Standard No 31 32 33 34 35 36 Score x x x 1 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Summerlodge Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score 2 x 2 x x 2 x I56 S49088 Summerlodge V233910 130905 Stage 4.doc Version 1.30 Page 21 YES 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. 2. Standard YA1 YA5 Regulation 5 (1) & (2) 5 (1) (b) Requirement Each service user must have an up to date service users guide Each new service user has a signed and dated contract/terms and conditions in accordance with the requirements of the National Minimum standards for Younger Adults. The registered manager develops and agrees with each service user an individual plan of care. Service user’s are empowered to make decisions about their own care, and are involved in the care plan process and day-today running of the home. Detailed and specific risk assessments are conducted and recorded within service user’s care plans and reviewed monthly. The registered person must ensure that there is a policy and staff adhere to the procedures for the receipt of recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own Timescale for action 12th December 2005 12th December 2005 3. YA6 15 (1) 12th December 2005 12th December 2005 12th December 2005 12th December 2005 4. YA7 12 (2) 5. YA9 13(3)(c) 13(4) 6. YA20 13 (2) 17 (1) 12 (1) – (4) 13 (4) 14 (2) Summerlodge I56 S49088 Summerlodge V233910 130905 Stage 4.doc Version 1.30 Page 22 7. YA34 8. YA35 7, 9, 19 (1) to (7) Schedule 2 12(1) & 18(1) 9. 10. YA37 YA42 8 (1) 12(1) medication if they wish, within a risk management framework. The registered person operates a robust and thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. The Registered Person must ensure that there is a staff training and development programme which meets National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. The acting manager must be registered and undertake NVQ level 4 in care and management. The registered manager ensures as far as is reasonably practicable the health, safety and welfare of service users and staff. 12th December 2005 12th December 2005 12th December 2005 12th December 2005 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. 3. Refer to Standard YA15 YA17 YA39 Good Practice Recommendations It is recommended that a visitors policy be made available It is recommended that service users preferences regarding their food presentation b e recored especially if pureed totally together. The CSCI should be informed of any results arising from formal and informal quality audit and monitoring within the home. Summerlodge I56 S49088 Summerlodge V233910 130905 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Kingswood House Baxter Avenue Southend-On-Sea Essex, SS2 6BG National Enquiry Line: 0845 015 0120 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 Summerlodge I56 S49088 Summerlodge V233910 130905 Stage 4.doc Version 1.30 Page 24 - 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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