Inspection on 29/11/06 for The Lodge, Exmouth

This inspection was carried out on 29th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Lodge, Exmouth 30/11/09

The Lodge, Exmouth 01/12/05

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 The Lodge, Exmouth 207 Exeter Road Exmouth Devon EX8 3DZ Lead Inspector Belinda Heginworth Key Unannounced Inspection 29th November 2006 09:00 The Lodge, Exmouth DS0000065098.V298881.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, Exmouth DS0000065098.V298881.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, Exmouth DS0000065098.V298881.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Lodge, Exmouth Address 207 Exeter Road Exmouth Devon EX8 3DZ 01392 462512 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) Devon Partnership NHS Trust Mrs Deborah Louise Brown Care Home 4 Category(ies) of Learning disability (4) registration, with number of places The Lodge, Exmouth DS0000065098.V298881.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age range category is 18 to 40 years. Date of last inspection 1st December 2005 Brief Description of the Service: The Lodge provides personal care and support for up to four residents with a learning disability. The home is operated by Trust Residential Services. Although the house is on two levels, all accommodation is on the ground level. The second floor is not accessible. There are four en-suite bedrooms, a large kitchen / dining room, a lounge and an office / sleep in room. There is a large pleasant garden to the rear of the property. The home is decorated and furnished to good standard creating a warm and homely atmosphere. Information received prior to the inspection indicated that current fees are £2670. Currently there are no additional charges for any services. The manager provides the most recent CSCI inspection report to service users and their relatives during the admission process. Subsequent reports are made available and explained to service users on request. The Lodge, Exmouth DS0000065098.V298881.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place over 5 hours in the home and 15 minutes at Trust Residential Services (TRS). This was to look at recruitment files. The manager was present for the majority of the inspection. Three out of the four service users living at the Lodge have extremely limited verbal communication skills. They were unable to contribute verbally to the inspection process. Time was spent talking with one with service user and observations were made throughout the inspection. On the day of the inspection 6 carers were present. Two were regular agency staff, two had only worked at the home for 3 days and were completing their induction training, one had worked at the home for two weeks and one was a more experienced staff member. All staff were spoken with during the inspection. Prior to the inspection the manager completed a questionnaire. This provides information about service users, staffing, fees and confirms that necessary policies and procedures are in place. Surveys were sent to service users and staff prior to the inspection. At the time only two service users were living at the home. Comment cards were also sent to professionals who are connected to the home and questionnaires were sent to relatives. Two service user surveys were returned, which were completed by staff through discussions and observations with service users. One relative questionnaire was received. Two staff surveys were returned and two comment cards were received from professionals involved with the home. All comments received were very positive about the home and the services. The inspector “case tracked” four service users. This means the inspector spoke with staff about individual care, read service users’ records in depth and made observations. The inspector looked around the building and other records were inspected. These included, fire safety logbook, staff rotas, menus, quality assurance records and financial files. What the service does well: Service users are provided with high levels of staff who have the experience and skills to meet their complex needs. Social and leisure needs are well met with plenty of opportunities to use local and surrounding facilities. Throughout the inspection, staff were observed being respectful, kind and caring, constantly encouraging independence and including service users, wherever possible, in decision making. One service user spoke about how “nice” the staff were and was observed “bantering” and having “jokes” with them. The Lodge, Exmouth DS0000065098.V298881.R01.S.doc Version 5.2 Page 6 The staff team work hard to communicate effectively with service users who have considerable difficulty in expressing themselves. Through the effective use of symbols, pictures and sign language they are able to ensure, as much as possible, that service users are understood and their needs are met. Staff demonstrated an excellent knowledge and understanding of service users’ needs and risks. This was described in service users’ files accurately. The training provided to staff is very good and ensures they have the skills to help them meet service users’ needs safely. Service users’ care plans and assessments of risk provide staff with excellent information and guidance on how to meet service users’ needs consistently and safely. The health needs of service users are monitored and well met. A comment from a GP said “A well run home”. Medication practices ensure service users’ welfare is well protected. The home has excellent systems in place to ensure service users are fully protected from potential abuse, through staff training and understanding of abuse and good recruitment, adult protection and financial procedures. The manager has excellent leadership skills and ensures the home is run well and safe by providing a clear policies, training and a clear sense of direction to staff. She constantly checks that the home is run in the best interests of service users. Relatives, service users and service users’ representatives are always involved and consulted about all aspects of care. The manager intends to develop the home’s quality monitoring systems further. What has improved since the last inspection? What they could do better: The manager is constantly carrying out reviews and coming up with new ways to improve the service, the most recent being person centred care plans which the manager hopes introduce early next year. Now that there is a stable team in the home, the manager should ensure that at least 50 of the team are on their way to obtaining qualifications in NVQ level 2 or above, or equivalent. This will ensure staff are suitably qualified. Although the home has good systems to monitor and measure how well the service is being run, this should be developed further to included ways of seeking the views of service users with poorer verbal communication. These quality assurance systems should also be formalised to ensure there are clear time scales of what should be completed, by whom and when. The Lodge, Exmouth DS0000065098.V298881.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, Exmouth DS0000065098.V298881.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, Exmouth DS0000065098.V298881.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 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service Service users and their representatives are able to make an informed choice before deciding to live at the home through the information provided. Service users are assured their needs will be met by the home before moving in, through good admission processes. EVIDENCE: The home has a Statement of Purpose that provides service users, relatives and professionals with information about the home. Each service user is provided with Terms and Conditions of occupancy. This ensures that service users or their representatives know what services will be provided within the fee structure. The manager does not have a specific format for assessing someone’s needs before they move in. Despite this, the manager ensures that enough information is gathered, to enable the home to assess whether the service users’ needs can be fully met. Excellent and detailed information was obtained for two service users who have recently moved to the home. Some of the information was provided by previous placements and care managers. Trial visits to the home and to the service users’ previous placements ensured staff The Lodge, Exmouth DS0000065098.V298881.R01.S.doc Version 5.2 Page 10 and service users got to know each other and the home. Due to the communication difficulties of these service users they were unable to talk about the process, but observations made on one service user indicated they were relaxed and settled. One service user was provided with photographs of the home, staff and other service users before they moved in. This helped them become familiar with the surroundings and the people they would be sharing with to ease the settling in period. Staff said they felt the information provided before someone moved in helped them to understand their needs. Some agency staff currently working at the home had worked with one service user at a previous placement. The staff came over with the service user to help ease the move. A relative who responded to a questionnaire sent by the CSCI said they were fully involved in the admission process and felt confidant that the home could meet their relative’s needs. One service user remembered visiting the home before moving in and felt happy with the process. The Lodge, Exmouth DS0000065098.V298881.R01.S.doc Version 5.2 Page 11 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 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Excellent information is provided to staff to help them to meet service users’ needs and goals safely and consistently. Decisions made on behalf of service users are done so in consultation with their representatives and in their best interests. EVIDENCE: Three out of the four service users living at the home have extremely limited verbal communication skills and limited understanding of a care plan. Therefore there are unable to verbally help in their formulation and review. In these circumstances care plans are produced through observations, information from pre-admission assessments and consultation with relatives and care managers. One relative confirmed they were fully consulted about the information in the care plan. The Lodge, Exmouth DS0000065098.V298881.R01.S.doc Version 5.2 Page 12 One service user knew about their care plan and was consulted about the information within it. Staff demonstrated an excellent knowledge of the information in care plans and were able to accurately describe service users’ needs and risks. Throughout the inspection staff were observed being kind, respectful and offering service users choice. Staff were also observed communicating effectively, on some occasions, through the use of simple sign language. The manager has completed in depth training on how to complete person centred plans, she hopes to implement these in the next few months. The current care plans provide excellent information about service users needs, likes, dislikes and risks. There are clear guidelines for staff to follow, for example, how to reduce anxieties and distress for service users who may become more challenging, how to communicate effectively and what actions need to be taken to keep service users safe and reduce any risks. Any practices that may restrict service users’ freedom of movement or choice are discussed and agreed within a multi-disciplinary setting (A Good Practice Committee) to ensure such decisions are made in the best interests of service users. Examples of such decisions are- the use of a harness in the home’s transport, and a buzzer on a bedroom door. The manager also intends to take issues relating to some en-suite facilities being locked when some service users are unsupervised and the occasional locking of a wardrobe door in certain circumstances. Decisions are clearly recorded and reviewed and form part of a detailed risk assessment, thus ensuring service users remain safe. It was clear through the evidence gathered and observations made during the inspection that the manager and staff are committed to providing care that is person centred. Staff receive a good level of training that helps them to understand and meet service users’ needs. (See section 31 – 36) The Lodge, Exmouth DS0000065098.V298881.R01.S.doc Version 5.2 Page 13 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from accessing the local community and taking part in appropriate activities. Service users’ rights are respected at all times and relationships with families are maintained. Service users benefit from a healthy and varied diet with individual choices and preferences respected. EVIDENCE: It was clear through observations made and talking with one service user and staff that the relationship between them is respectful, fun and caring. One relative who responded to a questionnaire said, “the staff are lovely and always keep me informed”. Care plans clearly describe how to approach and communicate with service users. As part of the induction process the manager discusses the use of respectful language when speaking to or writing about service users. Service The Lodge, Exmouth DS0000065098.V298881.R01.S.doc Version 5.2 Page 14 users’ daily records were written in a manner that reflected this and confirmed that the ethos of the home is very much person centred. Staff were observed being kind, respectful and offering choices. On the day of the inspection one service user was at school and the three remaining were given a choice of what they wanted to do. One went to collect a relative who came back to the home for lunch, another expressed a wish to buy a new music CD and was joined by the third person in the shopping trip. The staff team are committed to providing activities that are service user focused and take into account their needs and preferences. Staff have an excellent knowledge of service users’ needs, likes and dislikes. Activities take place from this knowledge and observations made during activities. These range from walks, shopping, pubs, cafes, farm work, college, library and many more. Staff support service users to maintain contact with relatives. Some service users visit their families regularly. Feedback received from a relative said – “staff are always polite” but also added “ I think a sensory room should be built”. Staff were observed making a relative very welcome during lunch, it was clear there was a good relationship. Although the home has menus, staff admitted they are rarely used. Service users are consulted daily about what they would like to eat. This was observed at lunchtime. Individual daily records are kept of foods eaten, these showed a varied, healthy and balanced diet is provided with fresh fruit and vegetables provided most days. Care plans also describe service users likes and dislikes and indicate any special diets needed, for example, one service user requires food to be chopped up and “wet” to help with swallowing. This was observed being carried out at lunchtime. The Lodge, Exmouth DS0000065098.V298881.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 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users’ dignity and privacy is respected and they benefit from their health needs being closely monitored to ensure they are well met. Medication practices protect service users health and welfare. EVIDENCE: Staff demonstrated a good knowledge and understanding of how service users preferred to receive personal care. Care plans provide staff with information on personal care and how much support is necessary. Staff were observed providing care in a respectful and sensitive manner. The home has separate records for health care assessments, monitoring and action taken. These showed that health care needs are well met with regular monitoring through GP’s and other health care professionals. These are also reflected in care plans and risk assessments. Feedback was received for two GPs, one had no comment to make, the other indicated they were satisfied that the home ensures health care needs are The Lodge, Exmouth DS0000065098.V298881.R01.S.doc Version 5.2 Page 16 appropriately met. Service users are supported by staff to attend medical appointments and visits from health professionals, to the home, take place in private. The service users are unable to manage their own medication safely, therefore staff administer it on their behalf. Staff who have responsibilities for this have recently received appropriate training and their competencies will be regularly assessed through supervision. In addition, all staff have to complete a workbook that is signed by the manager or senior staff to say they have observed medication procedures 5 times and are observed administering medication 5 times. Policies and procedures relating to medication practices have to be read and understood. These stringent standards ensure service users health and welfare is protected. Medication is supplied in a monitored dosage system (Blister packs), boxes, liquids and creams. It is stored in a locked cupboard secured to the wall of the office / sleep in room. The cupboard was found to be tidy and medication administration sheets appropriately used. A good audit trail of medication received and returned to the pharmacy is kept. Homely remedies that can normally be bought over the counter are generally prescribed by the GP, therefore the home does not have a Homely Remedy policy. The manager agreed to obtain this policy through the pharmacy and keep a small stock of these medicines. This would enable service users to receive medication to relieve some systems quickly, for example, sore throat or cough remedies. The Lodge, Exmouth DS0000065098.V298881.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Relatives and service users are assured they are listened to and complaints are dealt with appropriately. Service users are fully protected from potential abuse. EVIDENCE: The Commission and the home have received no complaints since the last inspection. The home has a detailed complaint’s procedure, which is displayed in the entrance hall. A response from a relative indicated they were not aware of the home’s complaint’s procedure but felt confident that any concerns they had would be dealt with appropriately. Staffs’ excellent knowledge of service users helps them to identify when service users are unhappy and take action to resolve it. Feedback from a care manager confirmed that staff work hard to ensure service users remain comfortable and happy. One service user said if they weren’t happy they would talk to the manager. All but the new staff have received adult protection training. The home also has Adult Protection and reporting policies available, including the local “alertor’s Guide”. The new staff were observed reading this. All staff spoken with demonstrated an excellent understanding of abuse awareness and what action to take if necessary. They were able to describe many types of abuse, including financial, verbal, physical, psychological and using medication inappropriately. The Lodge, Exmouth DS0000065098.V298881.R01.S.doc Version 5.2 Page 18 One service user manages their own money with the support of staff. They have their own bank account and are supported to go to the bank to pay in or withdraw money. Records are kept by the home but signed by the service user and staff. Two other service users’ relatives manage their monies and provide the home with spending money as and when required. Good records and receipts are kept. The manager periodically sends the receipts to relatives. The manager is to become appointee for one service user. Benefits will be paid into the service user’s bank account, which is also operated by the manager. Good records are kept of all financial transactions; monies kept on service users’ behalf are checked by two staff at each change of shift. These practices protect service users from potential financial abuse. The Lodge, Exmouth DS0000065098.V298881.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are provided with clean and comfortable surroundings that meet their needs. EVIDENCE: The Lodge is situated on the main road to Exmouth; it is used as a bungalow although it has two levels. The upper level is not accessible to staff or service users. The house has 4 en-suite bedrooms, a large lounge, a huge kitchen/dining room, a laundry room, toilet and office / sleep in room; and a large garden to the rear of the property. There is ample parking at the front of the house on a driveway. Service users’ bedrooms are decorated and furnished according to their needs, preferences and taste. For example, a service user who enjoys some sensory stimulation has a small ball pool in their room. Communal areas are decorated and furnished to an adequate standard, which creates a warm, homely and safe environment. The Lodge, Exmouth DS0000065098.V298881.R01.S.doc Version 5.2 Page 20 One service user said they liked their bedroom and said they helped choose the decoration and furnishings to personalise it to their taste. Other service users were observed relaxing in communal spaces. On the day of the inspection the home was generally clean and tidy although the windows were dirty inside and out. The Lodge, Exmouth DS0000065098.V298881.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, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported by competent and trained staff in enough numbers to meet their needs. Service users are protected by robust recruitment procedures. EVIDENCE: Most days and evenings there is a minimum of four to five staff on duty with one wake-in and one sleep-in at night. This number of staff ensures that the service users’ needs, which are often complex and challenging, can be met safely. Many staff have received a range of good practice training to help them understand and meet service users’ needs. Examples are - epilepsy, autism, breakaway techniques, gentle teaching and mandatory health & safety training. Total communication has been booked for next year. This help staff to learn different methods of communication. Some staff have achieved the foundation level in the Learning Disability Award Framework (LDAF), these are standards expected of staff working with people with a learning disability, the remaining staff are booked to start this. Only two staff have obtained NVQ The Lodge, Exmouth DS0000065098.V298881.R01.S.doc Version 5.2 Page 22 level 2, the manager said she is hoping more staff will start this next year. Despite this, staff receive a good level of training and it was clear through reading care file, talking with a service user and observations throughout the inspection that service users’ needs were fully met. New staff confirmed that reading and understanding care plans and risk assessments was part of the induction training. Care practices are also discussed during supervision and team meetings. Some staff felt there had not been enough team meetings recently and that communication between staff could be improved. The manager was aware of the problems and hoped to address the issues now that the home had a full compliment of staff. Recruitment practices are robust and protect service users from potential abuse. This includes ensuring new staff do not work in the home until satisfactory police checks are completed and appropriate references are obtained. A good induction takes place in the home within the first few days of working there and additional induction training is provided by TRS within a few months, covering, health & safety issues and adult protection. The Lodge, Exmouth DS0000065098.V298881.R01.S.doc Version 5.2 Page 23 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a home that is well managed with good systems that review, develop and improve the home. However, further development is required to ensure the home, is run in service users’ best interests. Service users safety and welfare are well protected. EVIDENCE: The manager has many years of experience in running care homes and has obtained the necessary qualifications and training to remain competent. Staff spoke very highly of the manager’s leadership style and said she provided an excellent and clear sense of direction and was extremely supportive. A relative who responded to a questionnaire indicated they were fully satisfied with the management of the home. The Lodge, Exmouth DS0000065098.V298881.R01.S.doc Version 5.2 Page 24 Throughout the inspection the manager was observed giving clear directions to staff and had a good relationship with service users, who responded well to her. The manager has systems in place that regularly reviews the quality of care service users receive. For example, information relating to service users is reviewed and up dated regularly. This ensures staff are aware of any changes and the care is appropriate and up to date. A relative said they were always kept informed of any changes and always attended reviews. Staff supervision, training and team meetings also ensure the home is run in a manner that includes all staff. Policies are reviewed and updated yearly, or when necessary. The manager also ensures all records in the home are monitored, reviewed and updated and ensures staff are aware of changes. There are excellent systems that monitor service users’ finances, therefore protecting service users from potential financial abuse. Trust Residential Services carry out monthly visits to the home, where inspections of records, including financial records, observations, and environmental checks and talking with staff and service users takes place. Reports are produced and copies are sent to the Commission. Recently the manager has produced ideas on how a quality assurance system that suits the communication needs of service users can be implemented. The manager wants to ensure service users views are sought but realises this is not easy when there is limited communication. However, a system that seeks the views of service users, staff, relatives and professionals involved in the home should be sought to ensure the home is run in the best interest of service users. This information should be collated and an improvement / development plan should be produced with clear action on how to improve the service. The fire logbook was found to be up to date and accurate. Fire risk assessments and staff training were completed, therefore protecting service users safety and welfare. The CSCI obtains a pre-inspection questionnaire prior to the inspection. This provides the Commission with up dated information on the home, services, staff and service users. This information, along with surveys, the site visit and talking with service users, staff and the manager helps the Commission to form a judgement on how well the home is run. The Lodge, Exmouth DS0000065098.V298881.R01.S.doc Version 5.2 Page 25 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 4 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 4 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 4 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 X 4 X 3 X X 3 X The Lodge, Exmouth DS0000065098.V298881.R01.S.doc Version 5.2 Page 26 No 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. Standard Regulation Requirement Timescale for action 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. Refer to Standard YA35 Good Practice Recommendations The home should have systems in place to ensure at least 50 of the staff team have achieved qualifications in NVQ level 2 or above, or equivalent. The home’s quality assurance systems should be further developed to ensure there is a clear plan of what work should be completed, with timescales and who is responsible. The plan should also include formal methods of seeking the views of service users with poor communication. 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