Inspection on 05/09/06 for The Lodge

This inspection was carried out on 5th September 2006.

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 no outstanding requirements from the previous inspection report, but made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Lodge 17/08/07

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 The Lodge 207 Scar Lane Milnsbridge Huddersfield West Yorkshire HD3 4PZ Lead Inspector Alison McCabe Unannounced Inspection 5th September 2006 10:25 The Lodge DS0000065604.V296159.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 The Lodge DS0000065604.V296159.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. The Lodge DS0000065604.V296159.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Lodge Address 207 Scar Lane Milnsbridge Huddersfield West Yorkshire HD3 4PZ 01484 460051 01484 460400 CragsideHouse@valeoltd.co.uk 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) Valeo Limited Mr Martin Nicholson Care Home 7 Category(ies) of Learning disability (7) registration, with number of places The Lodge DS0000065604.V296159.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Seven service users with learning disabilities Date of last inspection First inspection Brief Description of the Service: The Lodge is a residential home divided into two separate units. It is owned and managed by Valeo Community Projects, a private company. The Lodge provides a service for up to seven adults with learning disabilities and complex behaviours that challenge. The Lodge shares the site with Cragside House, also owned and managed by Valeo Community Projects, and was registered as a separate service from Cragside House in October 2005. The two units, one for three service users and one for four service users, is connected by a central office area. The home is close to community facilities including, shops, cafes, bank, post office and garden centre, and is on a major bus route. The range of fees for this service is between £1056 and £2356 per week. The Lodge DS0000065604.V296159.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of this key inspection, a site visit was conducted at The Lodge by one inspector between the hours of 10.25am and 5.45pm. In addition to the site visit, information used to inform the inspection includes notifications received from the home about any accidents, incidents or events that affect the well being of residents; provider monthly visit reports submitted to CSCI; the preinspection questionnaire submitted to CSCI prior to the site visit; completed questionnaires from three service users (and on behalf of three service users – completed by staff), and three relatives of service users giving views about the quality of the service. The manager has explained that three of the six service users were unable to complete the questionnaires due to their level of learning disability; staff therefore completed these on the service users’ behalf. Questionnaires were sent to six relatives - three have been returned; four visiting professionals - none have been returned; one GP (in respect of all service users currently accommodated) – none have been returned. Comments and feedback have been included within the main body of this report although the general feedback has been positive with all respondents expressing general satisfaction with the service provided at The Lodge. As part of the site visit, the inspector had the opportunity to talk to three members of staff including project worker, deputy manager and the registered manager. Communal areas and some service users’ bedrooms were seen. Records relating to service users, health and safety, staff training, staff recruitment, staff rotas and menus were examined as part of the site visit. Medication and records relating to medication were examined. The inspector also had the opportunity to observe care practice and the evening meal being served. This is the first key inspection at the Lodge since it was registered in October 2005 therefore there are no requirements or recommendations to check progress on. Some requirements and recommendations were identified during the site visit and these were discussed with the manager or deputy manager at the time. The inspectors would like to thank the service users and staff for their cooperation and hospitality during the site visit. What the service does well: Before service users move into the home, their needs are properly assessed. Service users are given information about the home before they move in. This helps to make a decision about whether or not to live at The Lodge. The Lodge DS0000065604.V296159.R01.S.doc Version 5.2 Page 6 Service users are supported to make decisions and staff respect their rights. Detailed care plans are in place for service users informing staff how to meet individuals’ assessed needs. Some service users have regular access to community-based activities. Staff offer good support to service users to enable them to maintain contact with their families and friends. Good food is provided at this home. Service users are supported to have their health and personal care needs met. Medicine management is generally good at this home. The home has a clear complaints procedure and service users know how to use this. Adequate policies and procedures are in place to protect service users from abuse. Service users live in a clean and spacious environment. Relevant training is provided to staff. The Lodge is a well run home. Good systems are in place to seek the views of service users and their families about the service they receive. What has improved since the last inspection? What they could do better: Further development of some risk assessments and behaviour management plans is necessary. More staff are needed on duty in the upper lodge. The project workers and manager need to continue with the progress they are making towards achieving their NVQ qualifications. Some areas need to be re-decorated, refurnished or repaired. The Lodge DS0000065604.V296159.R01.S.doc Version 5.2 Page 7 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 Lodge DS0000065604.V296159.R01.S.doc Version 5.2 Page 8 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 The Lodge DS0000065604.V296159.R01.S.doc Version 5.2 Page 9 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): 1,2 Prospective service users are usually given the information they need to make an informed decision about where to live. Adequate assessments are completed prior to service users being admitted to the home. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Six service user surveys were completed as part of this key inspection. A member of staff completed three on behalf of service users and three were completed by service users with staff support. Two service users indicated that they were given enough information about the home and were asked if they wanted to move in, whilst one service user stated that they had not been given sufficient information and had not been asked. Surveys completed on behalf of service users state that, due to their level of learning disability, their parents were consulted as part of the process. Records for two service users were examined as part of this site visit. Both contained complete and comprehensive assessments that had been conducted prior to them moving into the home. The Lodge DS0000065604.V296159.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Detailed care plans are in place for service users informing staff how to meet individuals’ assessed needs. Further development is necessary in some areas. Service users are supported to make choices about their lives. Action is taken to minimize identified risks to service users, although records require updating in some areas. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Individual care plans for two service users were seen and both contained clear information about how identified needs should be met. Further development of behavioural management plans, including the planned use of physical intervention, is required. This was discussed with the manager at the time of the visit and he was advised to refer to the Department of Health guidance in respect of physical intervention. Clear risk assessments that gave useful information to staff were in place in those records that were examined, and evidence that they were reviewed The Lodge DS0000065604.V296159.R01.S.doc Version 5.2 Page 11 regularly was seen. A number of incidents of service user to service user assaults have taken place at this home. Further risk assessments regarding challenging behaviour and physical intervention must be completed to ensure the protection of service users and staff. This was discussed with the manager at the time of the visit who has since arranged for the accredited physical intervention trainer from Valeo to visit the home to complete this. A number of examples of good care practice were observed during the site visit. Service users were observed making choices about what they wanted to do, eat, drink etc. Restrictions placed upon service users were clearly recorded in the individual care plans and the rationale for any such restrictions was apparent. Completed service user surveys show that most service users feel that they can choose what they do all of the time. One survey suggested that the service user did not think they could choose what they wanted to do, although there was some doubt as to the service user’s understanding of the questions and the accuracy of the responses. The Lodge DS0000065604.V296159.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Some service users have good access to daytime occupation whilst some service users have limited opportunities to take part in valued or fulfilling activities, education or training. Service users are supported to maintain contact with friends and family. Staff respect service users’ rights. Food provided is nutritious and varied. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Service users living in the lower and upper floors of the Lodge require very different levels of support and supervision. Service users living on the lower floor are much more independent and therefore, require less support to keep occupied and maintain community links. Through discussion with staff and service users, and observation during the site visit, it was apparent that these The Lodge DS0000065604.V296159.R01.S.doc Version 5.2 Page 13 service users have reasonable opportunities to access community-based activities and engage in meaningful activities. A service user who does voluntary work at a local charity shop said that they enjoyed this work. Two of the service users on the lower floor access the community independently if they choose to do so; both have keys to the front door and are free to come and go as they choose. Service users living on the upper floor are supported to access hydrotherapy and multi sensory facilities within other services run by Valeo. Opportunities to go out are limited, however, due to the levels of staff support that is required. The manager explained that there are ongoing discussions regarding staffing levels for the upper floor at the Lodge. A service user told the inspector that she and another service user had gone out for the day to celebrate her birthday and that she had enjoyed this. Valeo provides up to £500 per person each year to go on holiday. This money can be used for day trips or a stay away from home. Service users at The Lodge have had a variety of short breaks, longer stays and day trips this summer. A service user is being supported to go to see Tom Jones and Cliff Richard in concert, which will involve staying in London for two nights. She said she was looking forward to this. A record of service users’ preferences is kept as part of the care plan. This assists staff in selecting appropriate activities for those service users who have difficulty in communicating their wishes. Through discussion with service users, staff and examination of records, it is clear that service users are supported to maintain links with their families and friends. The relative of a service user visited during the site visit and reported that she was happy with the service and had no concerns. Feedback from relatives who returned the comment card to CSCI was all positive, stating that they felt well informed about their relative and are made welcome at the home. One relative said, “it is like a family”, at The Lodge. One relative commented that their son does not write to her as often as he used to; perhaps this is something that staff could discuss with the service user and offer support to keep in touch if this is what he wants. The daily routines at the home promote independence, individual choice and freedom of movement within the limits of reasonable risk taking. Service users on the lower floor have keys to their bedroom and front door if they want them. Staff were observed to ask permission of all service users before entering their bedrooms. Privacy locks are fitted on bathrooms, toilets and bedroom doors, and staff were observed to knock before entering. Service users on the lower floor have unrestricted access to all areas of their home with the exception of the office; this can be accessed with staff support. Service users on the upper floor do not access the kitchen area; it was reported that this was for health and safety reasons. Staff were observed to interact in a positive and respectful manner with service users, and included service users in conversations that were going on. Service users were observed to choose when to spend time alone or in the company of others. The Lodge DS0000065604.V296159.R01.S.doc Version 5.2 Page 14 Service users’ responsibility for household tasks is agreed and recorded and, where appropriate, risk assessments had been completed. Menus were examined and demonstrate that a varied and nutritionally balanced diet is offered to service users. Service users on the lower floor are encouraged and supported to take an active role in the planning and preparation of meals. One service user regularly cooks for herself and her housemates. A service user raised objections at having to plan a menu (for herself) in advance, stating that she much prefers to go shopping and decide when she is there what she would like. It was agreed at the time of the site visit that, providing a record was made of what the service user had eaten so that it was possible to check that a balanced and varied diet was being offered or encouraged, this would be in line with the Care Homes Regulations 2001. Food storage was satisfactory and a range of fresh fruit and vegetables was available. An extensive list of service users’ preferences was available which is good practice. Service users on the upper floor have less input although staff are aware of their preferences. The deputy manager explained that, due to infection control risks, service users on the upper floor do not have access to the kitchen. Staff do however support service users to participate in simple food preparation at the dining table. The inspector observed the evening meal being served. The food was nicely presented and was nutritionally balanced. Care is taken to ensure that the table is set with condiments, tablecloths and drinks are available. The Lodge DS0000065604.V296159.R01.S.doc Version 5.2 Page 15 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): 18,19,20 Staff offer personal support in the way that service users prefer and require. Service users are supported to have their healthcare needs met. Medicine management is generally good at this home. Quality in this outcome area is good. This judgement has been made from evidence gathered during the visit to this service. EVIDENCE: Service users at The Lodge require varied levels of support with personal care. Individual care plans contained excellent details about how service users prefer to be supported with their personal care routines. Times for meals, getting up, going to bed etc are flexible depending upon what service users have planned and their wishes. This was observed during the site visit. Service users are encouraged to choose what they would like to wear and appropriate support is offered. Each service user has two keyworkers. A service user told the inspector that she was asked her opinion about which staff member would be her keyworker and this is good practice. Staff were observed to offer support discreetly and with sensitivity. The Lodge DS0000065604.V296159.R01.S.doc Version 5.2 Page 16 Evidence that service users are supported to have their healthcare needs met was seen in records and confirmed through discussion with staff and service users. The CSCI had been notified of two incidents where service users required emergency medical attention. Satisfactory records had been maintained in respect of this. Service users are supported to access specialist services when required, for example, psychiatric and psychology services. Medicine management is good at this home. All medicines tallied with records kept. Clear protocols should be developed for the use of ‘as required’ (prn) medication to ensure that all staff are clear and consistent about when prn medication should be administered. This was discussed with the deputy manager at the time of the site visit. The Lodge DS0000065604.V296159.R01.S.doc Version 5.2 Page 17 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): 22,23 The home has a clear complaints procedure and service users know how to use this. Adequate policies and procedures are in place to protect service users from abuse although agreed strategies for the management of challenging behaviour must be developed. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: A satisfactory complaints procedure is in place. One complaint and one matter of concern have been received since the service was first registered in October 2005. The complaint is still in the process of being investigated. The concern raised was in relation to a service user being disturbed by noise at night. The manager reports that this was dealt with and resolved immediately. The monthly provider visit report of August 2006 highlights that this had not been recorded adequately, however the manager states that this has now been resolved. Feedback from service users able to complete the satisfaction survey was that they know how to make a complaint and know who to go to if they are not happy. Three relatives of service users also responded in the survey saying they knew how to make a complaint although none had had cause to do so. Procedures are in place for the protection of vulnerable adults. The organisation has an identified named co-ordinator for adult protection issues and staff at the home were aware of this. One referral has been made to Social Services Information Point regarding a protection issue. The The Lodge DS0000065604.V296159.R01.S.doc Version 5.2 Page 18 appropriate people were notified and reasonable steps were taken to protect the people concerned. A number of service user to service user assaults have taken place at this home since it was registered although there have been no incidents of this reported since 1st July 2006. In order to ensure the protection of all service users and staff, clear behavioural management plans and risk assessments must be developed. Staff must have clear guidance about how to respond to incidents of challenging behaviour; the guidance should include the use of prn medication and physical intervention if this is part of the agreed strategy. Financial records for two service users were examined and tallied with monies held. Clear systems were in place for recording and monitoring service users’ monies. The Lodge DS0000065604.V296159.R01.S.doc Version 5.2 Page 19 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): 24,30 Service users on the lower floor live in a clean and comfortable environment with plenty of useable communal space. Service users living on the upper floor live in a clean and generally comfortable environment; improvements could be made in some areas. Quality in this outcome area is good. This judgement has been made from evidence gathered during the visit to this service. EVIDENCE: All communal areas of the home, four occupied bedrooms and one vacant bedroom were seen as part of this site visit. The lower part of the home is comfortably furnished and homely. Service users’ bedrooms were personalised and comfortable. A service user on the lower floor has restricted access to clothing, however the deputy manager was able to give a clear rationale for this and explained that this had been agreed and recorded as part of the care plan. Evidence of this was seen in the records. Service users on the ground floor have access to a kitchen, lounge, dining room and a conservatory that is used as a smoking area. There are two bathrooms and a small laundry room. Service users on the lower floor have access to the laundry and take responsibility for their own washing, with the The Lodge DS0000065604.V296159.R01.S.doc Version 5.2 Page 20 appropriate support from staff. The office links the upper and lower parts of the home and this is not accessible to service users without staff being present. The lower floor has access to a private garden which has outdoor seating, patio and lawn areas. It was noted that an external power socket had no safety cover and this must be addressed; a requirement has been made in respect of this. The upper floor of the home caters for service users that require more physical support from staff. This was found to be less homely and comfortable. The deputy manager explained that, due to the needs of the service users, carpets have been replaced with floor covering that can be mopped easily. Due to identified risks, the usual items that would personalise a home are not in place, ie. ornaments, lamps etc. The manager is aware of the contrast between both floors and is in discussion with seniors within the organisation about the long term plans for this part of the home. Service users have access to a large dining area, and a lounge that is comfortably furnished is available. Bedrooms on the upper floor were not personalised to the same extent as the lower floor. This was reported to be due to the nature of some of the behaviours that are presented by the service users. A number of restrictions are placed upon these service users, for example, wardrobe doors are kept locked, bath taps are turned off, and the en-suite bathroom in one service user’s bedroom is kept locked unless it is in use. The deputy manager reported that these restrictions had been agreed as part of the individuals’ care plans. Records regarding this were not examined on this occasion. There is a small kitchen that is kept locked and this currently houses the washing machine and tumble drier; this could do with re-decoration. A separate laundry area has been identified and it is planned that these machines will be moved out of the kitchen in the near future. The manager reported that the machines would be replaced with commercial machines that have a sluice function and a larger capacity. There is a large conservatory attached to the house that is accessed from outside. This was being used to store mops and buckets and was unfurnished. The deputy manager reported that this space is not used often. Consideration should be given to how this area could be furnished so that it is a comfortable and safe area for service users to use. A yard area is available for service users use although there was no outdoor furniture. All parts of the home that were seen were clean and free from offensive odour. The manager reported that they are in the process of recruiting a cleaner for three hours per day, Monday to Friday. Of three surveys completed by service users, two stated that the home was always clean and fresh and one stated that the home was usually clean and fresh. The Lodge DS0000065604.V296159.R01.S.doc Version 5.2 Page 21 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): 32,33,34,35 Relevant training is provided to staff although 50 of staff are not appropriately qualified to NVQ level two or above. Staffing levels are adequate to meet the needs of the service users on the lower floor though not always on the upper floor. Generally good recruitment practice and procedures are in place. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: During the site visit, most staff were observed to interact with service users in a respectful and appropriate manner. Service users appeared to be comfortable with the staff and good relationships between staff and service users were evident. Service users spoken to at the time of the visit said that they got on well with most of the staff. Of three surveys completed by service users, two said that carers usually listen to them and act upon what they say, and one said that staff always listen and act upon what they say. When asked if the staff treat them well, as part of the survey, one said sometimes, one said usually and one said always. The Lodge DS0000065604.V296159.R01.S.doc Version 5.2 Page 22 Of sixteen staff, including seniors, the deputy manager and project workers, one has NVQ level 2 and one has NVQ level 3 in care. Two senior staff are working towards level 3, and seven project workers are working towards level 2. New staff complete the Learning Disabilities Award Framework induction and foundation training. It is a recommendation that 50 of all care staff achieve NVQ 2 in care. A comprehensive training programme is in place and training records examined demonstrate that relevant and regular staff training takes place. Staff recruitment records were sampled. Most of the required information was available with the exception of one member of staff’s records where only one reference was available. The manager explained that, due to the member of staff’s position changing, some records relating to him were at head office. It was agreed that this would be checked and, if the reference could not be located, it would be sent for again. Criminal Records Bureau (CRB) checks had been received in relation to all staff. The manager reported that the organisation’s policy was that staff must have a CRB check completed every three years; this is good practice. Clear records must be kept detailing discussion, risk assessment etc for any staff that do not have a clear CRB check. The manager reported that the only vacancy at present is for a domestic, three hours per day, 5 days per week. The pre-inspection questionnaire indicates that there has been very little staff turnover since the home was first registered. No agency staff have been used at this home. The staff team is made up of a registered manager, deputy manager, three senior project workers and twelve project workers. Most of the time, there are four project workers on duty per shift and sometimes five. This allows for two staff to be on each floor of the home, although the manager reported that sometimes three staff will work on the upper floor and one on the lower floor due to the higher level of care required by those service users. A service user commented that, due to the increased amounts of paperwork that staff now have to complete, they are not always available to spend time with service users. This was feedback to the deputy manager at the time of the site visit. Two service users on the upper floor are reported to receive funding for one to one carers, however if there are only two staff on duty on that floor, this is not possible. The manager needs to look at increasing the staffing levels on this floor to ensure that all service users are receiving the level of support they have been assessed as requiring. It was reported that the range of community based activities available to service users, particularly on the upper floor, is reduced when there are only two staff members available. One waking night staff and one sleeping member of staff cover nights. The sleep in staff member uses a fold down bed in the The Lodge DS0000065604.V296159.R01.S.doc Version 5.2 Page 23 dining room on the lower floor. This arrangement is not ideal as it prevents the service users from using their dining room and conservatory once the member of staff has gone to bed. The manager reported that it has been agreed that the sleep in bed will be moved into the office soon to allow service users access to all parts of their home. The Lodge DS0000065604.V296159.R01.S.doc Version 5.2 Page 24 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): 37,39,42 An experienced manager, who is working towards obtaining the appropriate qualifications, is running the home. Good quality assurance systems are in place at this home. The health, safety and welfare of service users is protected in most areas. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The registered manager has several years’ experience of working in a senior role with adults with learning disabilities and is currently working towards NVQ level 4 in care and management. He reported that he has completed most units and has two more to complete. Training records demonstrate that the manager attends regular relevant training in order to keep himself updated. The manager has an agreed performance criteria that is in line with his job description. Staff and service users reported having a positive relationship The Lodge DS0000065604.V296159.R01.S.doc Version 5.2 Page 25 with the manager. He is reported to be supportive and approachable, and was observed to manage the home in an open and positive manner. Quality questionnaires are sent to service users and their relatives every twelve months. Any concerns or complaints raised as part of this process are dealt with through the complaints procedure. The manager reported that feedback is also sought from relatives and service users at the six monthly reviews. The provider conducts monthly visits and a copy of the report is sent to the CSCI. The reports demonstrate that these visits are thorough and seek to gain the views of service users and staff in addition to sampling records and checking the environment. An action plan is agreed following the visit and progress is checked at the next visit and a record of this kept. This is good practice. A service user expressed her unease at being asked to complete a quality assurance questionnaire in order to inform the key inspection of this home. It was clarified at the time that there is no obligation to complete the questionnaire, as service users’ views will be sought during the site visit. The pre-inspection questionnaires indicate that regular safety checks and maintenance of equipment is carried out as required. Fire records show that fire alarm and equipment testing is carried out at the required intervals. As previously mentioned in this report, the outside power socket must be appropriately covered. The pre-inspection questionnaires states that all staff have received first aid training and evidence of this was seen in those staff records that were examined. Food hygiene and infection control measures are in place and evidence of this was seen during the site visit. In order to ensure the safety of all service users and staff, clear behavioural management plans must be in place, where necessary, including risk assessments and agreed physical intervention strategies. A requirement has been made in respect of this. The Lodge DS0000065604.V296159.R01.S.doc Version 5.2 Page 26 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 X 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 1 34 2 35 3 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 2 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 3 X X 2 X The Lodge DS0000065604.V296159.R01.S.doc Version 5.2 Page 27 N/A Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 YA23 YA42 2 YA9 YA23 YA42 Regulation Requirement Timescale for action 07/10/06 3 YA33 4 YA24 YA42 12(1)a,15(1), The service user plan must Sch 3 include details of any behaviour management plan including physical intervention plan (if required). 13(4) Detailed risk assessments must be developed regarding the use of physical intervention and the management of challenging behaviour. 12(1)b, The registered person must 18(1) ensure that at all times suitably qualified, competent and experienced persons are working at the home in such numbers as are appropriate for the health and welfare of service users. Staffing levels for the upper Lodge must be reviewed. 13(4)a The outside socket must be covered or removed. 07/10/06 31/10/06 30/09/06 The Lodge DS0000065604.V296159.R01.S.doc Version 5.2 Page 28 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 YA12 YA13 Good Practice Recommendations The registered person should make arrangements for all service users living at the home to have regular access to community activities and recreational and daytime occupation/education opportunities consistent with their interests and wishes. Clear protocols should be in place for the administration of ‘as required’ (prn) medication. The kitchen in the upper Lodge needs re-decorating. The conservatory in the upper Lodge needs furnishing. The registered person should continue working towards 50 of all care staff achieving NVQ level 2 or above. Clear records should be kept detailing discussion, risk assessment etc for any staff that do not have a clear CRB check. The registered manager should continue working towards achieving NVQ level 4. 2 3 4 5 6 7 YA20 YA24 YA24 YA32 YA34 YA37 The Lodge DS0000065604.V296159.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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 The Lodge DS0000065604.V296159.R01.S.doc Version 5.2 Page 30 - 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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