Inspection on 09/11/05 for The Lodge

This inspection was carried out on 9th November 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Lodge 28/10/08

The Lodge 18/10/06

The Lodge 19/04/05

The Lodge 26/10/04

The Lodge 17/06/04

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Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 The Lodge 21 Roundshead Drive, Off Jiggs Lane Warfield Bracknell Berkshire RG42 3RZ Lead Inspector Jill Chapman Unannounced Inspection 9th November 2005 10:15 The Lodge DS0000011048.V263737.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 The Lodge DS0000011048.V263737.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. The Lodge DS0000011048.V263737.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Lodge Address 21 Roundshead Drive, Off Jiggs Lane Warfield Bracknell Berkshire RG42 3RZ 01344 424982 01344 424982 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) Milbury Care Services Limited Ms Maria Rodriguez Care Home 5 Category(ies) of Learning disability (5), Learning disability over registration, with number 65 years of age (5) of places The Lodge DS0000011048.V263737.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users should not be admitted over 65 years of age. Date of last inspection 19th April 2005 Brief Description of the Service: The home provides care and accommodation for up to five service users with learning and associated physical disabilities. There are five single bedrooms; three on the ground floor and two on the first floor. There are bathrooms on the first and ground floor and one bedroom has an en-suite bathroom. There is a lounge/dining room, kitchen/dining room and a conservatory. There is off street parking to the front of the property. The home is staffed 24 hours a day. The Lodge DS0000011048.V263737.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 carried out on a weekday morning over a period of two and quarter hours. The focus of the inspection was to follow up progress from the last visit and to inspect the key standards that were not covered at the last visit. Three residents were at home at the time of the visit and some of the morning routine was observed. Discussion took place with a Senior Support Worker and a Support Worker. The premise were inspected and records were sampled. What the service does well: What has improved since the last inspection? Since the last inspection there has been a change of manager and this change has gone smoothly without adversely affecting the service. The outgoing manager, who managed the service well, gave a handover to the new manager and this has helped the smooth transition. The Lodge DS0000011048.V263737.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Lodge DS0000011048.V263737.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 The Lodge DS0000011048.V263737.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): Not inspected on this visit EVIDENCE: The Lodge DS0000011048.V263737.R01.S.doc Version 5.0 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 the following standard(s): Not inspected on this visit. EVIDENCE: The Lodge DS0000011048.V263737.R01.S.doc Version 5.0 Page 10 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): Not inspected on this visit. EVIDENCE: The Lodge DS0000011048.V263737.R01.S.doc Version 5.0 Page 11 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): Not inspected on this visit. EVIDENCE: The Lodge DS0000011048.V263737.R01.S.doc Version 5.0 Page 12 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 There is a system in place to deal with complaints. EVIDENCE: There is a complaints procedure in place. A requirement that staff should know where the complaints book is kept has been carried out. No complaints have been received and advice was given to record the date that the book was started. The Lodge DS0000011048.V263737.R01.S.doc Version 5.0 Page 13 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 The home provides spacious and homely accommodation for residents. Outstanding repairs compromise residents’ safety and comfort. The home is kept clean and hygienic to prevent infection. EVIDENCE: The home is located close to local shops and near to facilities in the town of Bracknell. The house provides homely accommodation and bedrooms reflect the interests and personalities of the residents who live there. The inspector looked around the building and it was found that there are a number of issues about the premises that need to be addressed. Records show that staff have reported these repairs to the maintenance department but they remain outstanding. • • • • The Velux window in a bedroom is leaking and needs repair or replacement. Part of the front of the central heating boiler is missing and needs replacing. In another bedroom there are damp patches by the sink, bay window and outside wall. The parking area floods when it rains. DS0000011048.V263737.R01.S.doc Version 5.0 Page 14 The Lodge • • Some kitchen drawer fronts are missing A ceiling needs repair in another bedroom. Since the last inspection a new fridge, fridge freezer, top loading washing machine, and tumble drier have been purchased. A new extractor fan has been fitted to the downstairs bathroom. The house was found to be clean and tidy. Cleaning responsibilities are highlighted on shift plans and this system ensures that tasks are carried out. The home does not handle any clinical or incontinence waste, however policies are in place to give guidance if this is ever needed. There is a designated laundry area and staff were aware of safe laundry practice. The Lodge DS0000011048.V263737.R01.S.doc Version 5.0 Page 15 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): 33, 34 & 35. There are enough staff on duty to meet residents current needs. There is a procedure in place to make sure that only suitable staff are employed which helps protect residents. Staff receive training to help them do their job properly and help them know how to meet residents needs. EVIDENCE: Rotas were sampled and show that there are two staff on daytime shifts and one waking and one sleep in night staff. The surnames of staff and their designation should also be shown on the rota. A requirement to identify a shift leader had been addressed by highlighting this on the rota. This was not shown on the November rota. Staff deployment appears to meet residents current needs. There is minimal use of agency and bank staff. Recruitment records could not be seen on this visit but Milbury recruitment procedure was confirmed by speaking to a new member of staff. The procedure includes taking up references, health and Criminal Records Bureau checks. The staff member confirmed that she received a detailed induction and that core training is booked. She has been impressed by the professional and supportive staff systems in place. Staff confirmed that they can access Learning Disability Award Framework and National Vocational Qualification training. Newer staff are currently undertaking The Lodge DS0000011048.V263737.R01.S.doc Version 5.0 Page 16 LDAF training before starting on NVQ. Training records were sampled and show that a variety of suitable training is available. The Lodge DS0000011048.V263737.R01.S.doc Version 5.0 Page 17 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): 39 & 42 Milbury carry out an Annual Audit but staff spoken to were not aware of this. There is generally good attention paid to health and safety matters but delays in essential repairs and providing hold open devices to fire doors potentially puts residents at risk. EVIDENCE: Milbury have a quality assurance system, which includes an Annual Audit of the service, and a copy of this was sent to CSCI. Staff on duty were not aware of this or where the copy is kept. Health and safety records were sampled and these were found to be up to date. A monthly health and safety audit and separate fire safety audit is carried out to identify shortfalls that need to be addressed. The registered persons need to address the ongoing delay in repairs being carried out. There is an outstanding requirement to fit suitable hold open devices to the lounge and kitchen doors. On this inspection it was also found that two The Lodge DS0000011048.V263737.R01.S.doc Version 5.0 Page 18 bedroom fire doors are routinely wedged open at night. This practice puts residents at risk should a fire occur. Hold open devices approved by the Fire Safety Officer should be fitted to these doors. These matters are subject to an immediate requirement from this inspection. The Lodge DS0000011048.V263737.R01.S.doc Version 5.0 Page 19 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 x x x x x Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score x x x x x Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X X 3 LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 x 16 x 17 Standard No 31 32 33 34 35 36 Score X X 3 3 2 X CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Lodge Score x x x x Standard No 37 38 39 40 41 42 43 Score X X 2 X X 2 x DS0000011048.V263737.R01.S.doc Version 5.0 Page 20 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 Standard YA42 Regulation 23(4) Requirement The Fire Safety Officer should be consulted about the most appropriate method of holding fire doors open and any recommendation carried out. • The Velux window in a bedroom is leaking and needs repair or replacement. Part of the front of the central heating boiler is missing and needs replacing. In another bedroom there are damp patches by the sink, bay window and outside wall. The parking area floods when it rains. Some kitchen drawer fronts are missing A ceiling needs repair in another bedroom. Timescale for action 30/11/05 2 YA24 23(2) 09/02/06 • • • • • 3 YA33 18.1(a) Schedule 4 The surnames of staff and their designation should also be shown on the rota. 09/12/05 The Lodge DS0000011048.V263737.R01.S.doc Version 5.0 Page 21 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Lodge DS0000011048.V263737.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Berkshire Office 2nd Floor 1015 Arlington Business Park Theale, Berks RG7 4SA 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. 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