Inspection on 28/02/06 for SummerLodge

This inspection was carried out on 28th February 2006.

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 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 6 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 13/09/05

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 Inspection 28th February 2006 10:00 SummerLodge DS0000049088.V272553.R01.S.doc Version 5.0 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 SummerLodge DS0000049088.V272553.R01.S.doc Version 5.0 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. SummerLodge DS0000049088.V272553.R01.S.doc Version 5.0 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 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) SummerCare Homes Ltd Ms Sheena Fleming Care Home 5 Category(ies) of Learning disability (5) registration, with number of places SummerLodge DS0000049088.V272553.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Personal care to be provided to 5 residents with a learning disability. Maximum number to be cared for 5 (five). The age of the service users will be between 18 and 65 years. Date of last inspection 13th September 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 DS0000049088.V272553.R01.S.doc Version 5.0 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 four hours with one inspector in the home. 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. Two members of staff were spoken with. Twenty-eight National Minimum Standards were inspected on this occasion, twenty-two overall outcomes were met and there were six requirements and six recommendations detailed in the full report. Discussion of the inspection findings took place with the 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: Each new service user requires a signed and dated contract/terms and conditions Omissions in medication recording and administration should be addressed. Staff including agency staff must have the competencies and qualities required to meet service users’ needs The Registered Person must ensure that there is a staff training and development programme and that updates are maintained. The registered person must ensure that the home has a registered Manager. An application must be submitted. Health and safety certificates for the environment must be kept up to date. SummerLodge DS0000049088.V272553.R01.S.doc Version 5.0 Page 6 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. SummerLodge DS0000049088.V272553.R01.S.doc Version 5.0 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 SummerLodge DS0000049088.V272553.R01.S.doc Version 5.0 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 the following standard(s): 1, 3, 4, 5 Present and prospective service users and their supporters are given adequate information about the home so that they can make informed choices. Each service user generally has a contract directly with the home if privately placed or a statement of terms and conditions if funded by social services, this was not the case in this instance regarding a recent admission. EVIDENCE: The home has produced its Statement of Purpose and Service Users Guide. The service users guide has been produced in pictorial form. The manager said all service users have had the service users guide explained to them. Service users are invited to stay at the home for a trial period prior to admission. During this period the views of existing service users with regards to the proposed admission are obtained and recorded. There has been one new admission to the home since then last inspection and it was evidenced that this service user visited the home on a number of occasions before taking up residence. The needs of service users are reviewed on a regular basis and the advice of specialist personnel sought as appropriate. Each service user is issued with a contract including terms and conditions of occupancy on admission to the home, these are still being developed pictorially. The contract for the most recent admission was noted to be unsigned and undated and there was no documentation or COMM 5 assessment regarding their funding arrangements. This was noted at the last inspection and recommended that individual contracts include the SummerLodge DS0000049088.V272553.R01.S.doc Version 5.0 Page 9 arrangements for holidays where service users do not wish to take a seven-day break from the home. SummerLodge DS0000049088.V272553.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, 10 Each service user has an individual plan and 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: SummerLodge DS0000049088.V272553.R01.S.doc Version 5.0 Page 11 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 been reviewed on a regular basis and where previously essential information was omitted regarding services users health and welfare this was now included. Service user involvement is limited due to the level of comprehension of the client group. The manager ensures that service users are offered opportunities to participate in the day to day running of the home as able. It is recommended that service users understanding of the care planned is assessed and documented. Service users at the home are encouraged to make decisions wherever possible. Some service users at the home use very basic makaton. A makaton package previously was being used in order to develop relevant policies and procedures in a format, which service users can understand. Service users views are obtained mainly through observation and staff knowledge of individual’s preferences and dislikes. Where limitations to choice have been imposed as noted at the homes previous inspection this has now been recorded for one service user who used a baby monitor. It was 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 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 still required prioritising and updated adequately. The home has a detailed policy for maintaining confidentiality. Staff spoken with said that they had received information with regards to confidentiality at induction and signed confidentiality agreements were seen. SummerLodge DS0000049088.V272553.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 14, 15, 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: Service users attend day centres and one service user attends school, and all are encouraged to learn and maintain practical life skills according to their capabilities. Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. Service users have their own televisions, some have music centres and DVD players. All service users have the opportunity of enjoying a holiday of their choice in the summer. 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. 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 and preferences for the presentation of their food is now recorded as it was highlighted at the last inspection. SummerLodge DS0000049088.V272553.R01.S.doc Version 5.0 Page 13 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 DS0000049088.V272553.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20, 21 Arrangements are in place to ensure that the health care needs of service users are identified and met. Omissions in medication administration were evident. EVIDENCE: 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 has been 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 has been 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 planned to be carried out and some administration omissions were noted which was highlighted at the homes last inspection also.. There is a policy in place, which deals with issues regarding death and dying. Service users wishes on death and dying have been sensitively obtained and recorded in individual careplans. As the home is a learning disability home and all the service users are quite young deaths in the home are very few and none have happened in the time the present manager has been in post. SummerLodge DS0000049088.V272553.R01.S.doc Version 5.0 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 the following standard(s): NOT INSPECTED EVIDENCE: NOT INSPECTED SummerLodge DS0000049088.V272553.R01.S.doc Version 5.0 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 the following standard(s): NOT INSPECTED EVIDENCE: NOT INSPECTED SummerLodge DS0000049088.V272553.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36 On the whole adequate recruitment policies and practices were in place. The home generally 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: Staff are issued with job descriptions which reflect the aims and objectives of the home and the needs of service users. Each member of staff is issued with a copy of the General Social Care Council (GSCC) standards of conduct. Staff spoken with demonstrated a sound knowledge of service users care needs and have access to a wide range of appropriate training updates were noted to be required. There was evidence to suggest that staff are employed in sufficient numbers to meet the needs of service users at the home and that staffing rotas are reviewed on a weekly basis. Currently the home has vacancies and uses agency staff to cover shifts. The inspector was concerned when the agency member of staff working on the day of inspection answered the door to her, did not ask for identification and left the door wide open whilst he went to find the permanent member of staff. Three service users were in the lounge and were not being attended to and the agency member of staff was not wearing any identification. When asked he stated his badge was in the car. The agency SummerLodge DS0000049088.V272553.R01.S.doc Version 5.0 Page 18 careworkers appearance was not considered appropriate and was wearing flip flops to undertake care duties. The inspector also had to prompt the agency staff member to attend to one service user who was trying to get his attention whilst the agency careworker sat watching television. These matters were bought to the attention of the manager on the day of inspection who assured the inspector that she would deal with the unsatisfactory situation and events. Two staff files were inspected. At the last inspection the most recent person employed had no documentation at all, and the other’s had several major omissions. This was noted to have now been recitified with only one member of staffs file not containing a contract. Original CRB checks should be kept on the premises. Staff recruitment files sampled did demonstrate on this occasion that good recruitment procedures are practiced. Records for agency staff must be kept also. 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. Staff receive supervision on a regular basis and this is recorded. SummerLodge DS0000049088.V272553.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40, 41, 42, 43 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. Some aspects of this regarding documentation could not be ascertained. EVIDENCE: The acting manager is still in the process of applying for registration and is currently undertaking NVQ level 4 in care and management. Quality monitoring systems are being developed further to include the views of service users families and friends and other stakeholders. Once completed a copy of the findings to be made available to service users and a copy forwarded to the CSCI in addition to the monthly, unannounced visit reports. The home has the full range of the proprietors policies and procedures. Staff are required to read these during their induction programme. The manager previously informed that the policies are discussed on occasions at staff meetings and during staff supervision. The homes policies and procedures are reviewed on a yearly basis unless otherwise required. Staff are involved in policy making wherever this is appropriate. SummerLodge DS0000049088.V272553.R01.S.doc Version 5.0 Page 20 Staff receive training in respect of identifying and assessing risks within the home environment and risk assessments for safe working practices are carried out. Information regarding health and safety issues was noted to be displayed prominently in key areas At the previous inspection work was ongoing within the home to comply with fire regulations and a number of safety certificates were not available to inspect such as the electrical and gas certificates. The homes electrical inspection was noted to be due and the bathroom window is still only partially opaqued and this needs to be completed. The manager was reminded that an up to date copy of certificates must be in the home and available for inspection. Service users monies when inspected highlighted a few discrepancies. It was reported that there is a business plan for the home however this was not inspected during this inspection. Records inspected were generally well kept and stored securely in the homes office. It is judged that procedures are in place to ensure appropriate management of the business and there was no evidence to suggest that the home is not financially viable. Evidence was seen of up to date Insurance Cover. SummerLodge DS0000049088.V272553.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 X 3 3 2 Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 3 12 X 13 X 14 3 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score 3 2 3 3 2 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 SummerLodge Score X X 2 3 Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 3 2 3 DS0000049088.V272553.R01.S.doc Version 5.0 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 YA5 Regulation 5 (1) (b) Requirement 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 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 medication if they wish, within a risk management framework. Staff have the competencies and qualities required to meet service users’ needs and achieve Sector Skills Council workforce strategy targets within the required timescales. 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 DS0000049088.V272553.R01.S.doc Timescale for action 14/04/06 2 YA20 13,17(1) 12, 14(2) 14/04/06 3 YA32 18(1) Sch 2(4) 14/04/06 4 YA35 12(1) & 18(1) 14/04/06 SummerLodge Version 5.0 Page 23 5 YA37 8(1,2)9 (1)&(2) 12(1) 6 YA42 changing needs of service users. This with reference to training updates The registered person must ensure that the home has a registered Manager. An application must be submitted The registered manager ensures as far as is reasonably practicable the health, safety and welfare of service users and staff. 14/04/06 14/04/06 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 4 5 6 Refer to Standard YA8 YA9 YA15 YA34 YA41 YA42 Good Practice Recommendations It is recommended that the minutes of home meetings are recorded as the home has not since 16/2/05 It is recommended that risk assessments are prioritised and updating accordingly It is recommended that a visitors policy be made available It is recommended that records be obtained in relation to agency care workers It is recommended that any discrepancies in service users monies be clarified and documented The upstairs bathroom window is only partially opaqued and should be fully frosted to maintain service user dignity SummerLodge DS0000049088.V272553.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection South Essex Local Office 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 DS0000049088.V272553.R01.S.doc Version 5.0 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!