Inspection on 16/01/06 for Titchfield Lodge

This inspection was carried out on 16th January 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Titchfield Lodge 23/10/07

Titchfield Lodge 19/07/06

Titchfield Lodge 30/08/05

Similar services:

Hillview Farm

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 Titchfield Lodge 66 Titchfield Park Road Titchfield Park Titchfield Hampshire PO15 5RN Lead Inspector Craig Willis Unannounced Inspection 16th January 2006 11:00 Titchfield Lodge DS0000063468.V276126.R01.S.doc Version 5.1 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 Titchfield Lodge DS0000063468.V276126.R01.S.doc Version 5.1 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. Titchfield Lodge DS0000063468.V276126.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Titchfield Lodge Address 66 Titchfield Park Road Titchfield Park Titchfield Hampshire PO15 5RN 01420 544118 01420 544140 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) ILIACE Limited Mrs Sharon Walton Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Titchfield Lodge DS0000063468.V276126.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th August 2005 Brief Description of the Service: Titchfield Lodge is registered to provide care and accommodation to four people with learning disabilities, between the age of 18 and 65. The accommodation is provided in a large detached house in Titchfield Park, approximately half a mile from local shops and transport links. Each service user has their own single bedroom and share the use of kitchen, lounge, conservatory and gardens. The home has a car which staff support service users to access. The home is managed by ILIACE, who have a number of similar services in Hampshire. Titchfield Lodge DS0000063468.V276126.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second inspection of the year April 2005 to March 2006. Key standards not covered in this report were assessed in the inspection of 30th August 2005. During the visit the inspector spoke with the manager, three staff members and a relative of one service user. Due to their communication needs, the inspector did not speak with the service users, although their interaction with staff was observed. What the service does well: What has improved since the last inspection? What they could do better: Titchfield Lodge DS0000063468.V276126.R01.S.doc Version 5.1 Page 6 The manager must ensure that the radiators in the home are covered. This is assessed as necessary to keep one service user safe in the event of a seizure. The home has a suitable complaints procedure. The manager should supply a copy of the procedure to service users’ representatives, as they are unlikely to be able to make a complaint themselves due to their communication needs. The manager must ensure that the medication training assessment is completed for all staff. 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. Titchfield Lodge DS0000063468.V276126.R01.S.doc Version 5.1 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 Titchfield Lodge DS0000063468.V276126.R01.S.doc Version 5.1 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): 5 Service users have an individual statement of terms and conditions with the home, enabling their representatives to know what level of service they can expect from the home. EVIDENCE: Since the last inspection, each service user has been supplied with a statement of terms and conditions of residency, specific to Titchfield Lodge. This document sets out the services that are included in the fee, notice period, items that are not covered by the fee and the rights and responsibilities of the provider and the service user. Titchfield Lodge DS0000063468.V276126.R01.S.doc Version 5.1 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): 6, 7 and 9 The home has good systems in place to plan and review how the changing needs of service users should be met and supports service users to make decisions. There is a suitable risk assessment system in place, although action is needed to ensure that action identified in the assessments is completed. EVIDENCE: The personal files of all three current service users were viewed during the visit. Since the last inspection all of the care plans have been re-written, to make them specific to the service users’ life at Titchfield Lodge. The plans set out how the service users’ assessed needs should be met. The plans are reviewed at least every six months, or as the needs of service users change. Due to the communication needs of service users, staff observe their reactions to events and recorded in their care plans what it is thought their likes and dislikes are. The care plans include how service users have communicated these likes and dislikes through vocalisations, signs and behaviours. Information is also available from service users’ relatives and care managers about their needs and how they should be met. Risk assessments were available for all service users, and included action that staff should take to minimise the identified risks. One service user’s risk Titchfield Lodge DS0000063468.V276126.R01.S.doc Version 5.1 Page 10 assessment stated that the radiators in the home must be covered to protect them from burns in the event of a seizure. The manager reported that although covers for the radiators had been ordered, they were waiting for them to be fitted. This work must be completed. Titchfield Lodge DS0000063468.V276126.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15 and 16 Service users are supported to take part in a good range of activities, including use of community facilities. Good support is provided for service users to maintain their personal relationships and staff respect the rights of service users. EVIDENCE: Since the last inspection the day activity programme has been revised and now includes cookery, swimming, sessions at a local activity centre, music and movement and trampolining. Following comments from one service user’s parent, a list of suggested activities for the evenings and weekends has been developed. Service users are supported to use local shops and pubs, and the manager reported that they had held a Christmas meal for all service users in a local pub. Details of the support service users need to maintain their personal relationships are contained in the care plans. Support included making regular calls to family members. The manager said she planned to provide more support for service users to write to their family and friends. Titchfield Lodge DS0000063468.V276126.R01.S.doc Version 5.1 Page 12 Details of the support service users need in relation to household jobs are included in the care plans and staff were actively supporting service users to be more aware of food preparation processes. Service users had unrestricted use of the home’s communal areas and staff were observed knocking on doors and letting service users know who it is before going into their bedrooms. Titchfield Lodge DS0000063468.V276126.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 The care planning system enables service users to receive personal support in the way they prefer and require. EVIDENCE: Details of how service users prefer to receive support with personal care is included in their care plans. The manager reported that this information is developed from observations of service users and information from family members taken from the initial assessment of the service user. This information is regularly reviewed and updated where necessary. Staff spoken with demonstrated a good understanding of the details in the care plans. Staff were observed supporting service users to go to private areas to receive personal care. The home operates a keyworker system, with that member of staff taking the lead in co-ordinating the service provided. Titchfield Lodge DS0000063468.V276126.R01.S.doc Version 5.1 Page 14 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 The home has a suitable complaints procedure, although providing this document to service users’ relatives will enable them to advocate on the service user’s behalf if necessary. EVIDENCE: The home has a copy of the standard Iliace complaints procedure, which includes details of who will deal with a complaint, the time it will take for a complainant to receive a response and the contact details of the Commission for Social Care Inspection. The manager agreed that, due to the communication needs of the service users, she would ensure that a copy of the complaints procedure was supplied to their relatives. One relative spoken with said they had not needed to make a complaint and were not totally sure of the procedures to do so, but would speak with the manager if they had any concerns. No complaints have been received since the last inspection. Titchfield Lodge DS0000063468.V276126.R01.S.doc Version 5.1 Page 15 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): None The key standards were assessed in the inspection of 30th August 2005. EVIDENCE: Titchfield Lodge DS0000063468.V276126.R01.S.doc Version 5.1 Page 16 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 and 36 The home provides good support for staff to gain qualifications and service users are protected by the home’s recruitment and supervision of staff. The staff receive regular training to help them meet the needs of service users, although the medication assessments for staff need to be completed to ensure service users are protected. EVIDENCE: The home currently has one member of staff with NVQ level 3 and three staff who are completing the award. Other staff are due to start working on the award following the completion of six months service. The manager reported that she is an NVQ assessor and Iliace has recently become an NVQ assessment centre. The records of two staff that have started work since the last inspection were checked and found to contain all required documents, such as an enhanced disclosure from the Criminal Records Bureau, two written references and a completed application form. Staff have completed training courses in fire safety, first aid, epilepsy awareness, adult and child protection, food hygiene and moving and handling. The manager reported that she had observed all staff administering medication, although she has not assessed all of the training packs that staff have completed. These assessments must be completed. Since the last inspection the manager has introduced regular one to one supervision meetings for staff. Staff spoken with said that they found these Titchfield Lodge DS0000063468.V276126.R01.S.doc Version 5.1 Page 17 meetings useful and they enabled them to raise issues about the service being provided. The supervision records showed that staff had these sessions approximately every six weeks. The manager reported that she meets with the responsible individual formally every two months, but has more regular face to face and telephone contact, and feels well supported. Titchfield Lodge DS0000063468.V276126.R01.S.doc Version 5.1 Page 18 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 and 39 The home is well managed and the service provided is monitored and reviewed by the organisation. EVIDENCE: The manager has the NVQ assessor’s award and reported that she has started work on the registered manager’s award. She is supported in her duties by her manager and a senior support worker. Senior managers of Iliace visit the home every month to assess the service being provided and provide a copy of the report to the Commission for Social Care Inspection. The home has objectives for improvement that are set for the year and reviewed on a quarterly basis. The manager reported that Iliace had achieved the Investors in People Award. The awarding body has set a number of goals for the organisation to achieve and these must be met to retain the award. Titchfield Lodge DS0000063468.V276126.R01.S.doc Version 5.1 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 Standard No Score 1 X 2 X 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 X ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 X X X 3 X 3 X X X X Titchfield Lodge DS0000063468.V276126.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? No 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 YA9 Regulation 13 (4) Requirement The registered person must ensure that the radiators in the home are covered, in line with the risk assessments for one service user. The registered person must ensure that all staff complete medication training. Timescale for action 28/02/06 2. YA35 18 (1c) 28/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Titchfield Lodge DS0000063468.V276126.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Titchfield Lodge DS0000063468.V276126.R01.S.doc Version 5.1 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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