Inspection on 24/07/08 for West Lodge

This inspection was carried out on 24th July 2008.

CSCI found this care home to be providing an Excellent service.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

West Lodge 25/07/07

West Lodge 22/08/06

West Lodge 17/10/05

West Lodge 24/05/05

West Lodge 24/11/04

West Lodge 30/06/04

Similar services:

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Extracts from inspection reports are licensed from CQC, this page was updated on 09/11/2008.

CARE HOME ADULTS 18-65 West Lodge 39 Frederick Gardens Penshaw Houghton-le-spring Tyne And Wear DH4 7JY Lead Inspector Elsie Allnutt Key Unannounced Inspection 24th July 2008 10:00 West Lodge DS0000015758.V367751.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 West Lodge DS0000015758.V367751.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. West Lodge DS0000015758.V367751.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service West Lodge Address 39 Frederick Gardens Penshaw Houghton-le-spring Tyne And Wear DH4 7JY 0191 385 7169 0191 385 7169 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) www.c-i-c.co.uk. Community Integrated Care Ms Yvonne Marie Reay Care Home 6 Category(ies) of Learning disability (6), Mental disorder, registration, with number excluding learning disability or dementia (1), of places Physical disability (2) West Lodge DS0000015758.V367751.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registerd person may provide the following category of care: Care home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: Learning disability - Code LD, maximum number of places: 6 Physical disability - Code PD, maximum number of places: 2 Mental disorder, excluding dementia or learning disability - Code MD, maximum number of places: 1 The maximum number of service users who can be accommodated is: 6 25th July 2007 2. Date of last inspection Brief Description of the Service: West Lodge is a detached two-storey building, which was originally a private house. It is situated in a quiet location at the end of a cul de sac amongst a variety of private houses in Penshaw. Some structural alterations were undertaken prior to the homes registration but it retains its domestic appearance in many ways. There is a spacious drive sufficient to park four vehicles and local amenities such as a post office, corner shops, and pubs within a few minutes walking distance in Penshaw. The building provides six individual bedrooms, two of which are on the ground floor and four on the first. There is a large lounge/dining room kitchen and laundry room all shared by the service users, as well as accessible well-stocked gardens. The home is registered to offer a service to 6 people with a learning disability, including 2 who may have physical disabilities and 1 with additional mental health needs. This is for a specifically named person. The home has developed a Service User Guide that informs prospective service users about the service, the aims and how these are met. A copy of the recent inspection report is available in the home for anyone to read. The fees charged by the home are £952.54.47p per week. West Lodge DS0000015758.V367751.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 star. This means the people who use this service experience excellent quality outcomes. Before the visit: We looked at: • Information we have received since the last visit. • How the service dealt with any complaints & concerns since the last visit. • Any changes to how the home is run. • The provider’s view of how well they care for people. • The views of people who use the service & their relatives, staff & other professionals. The Visit: An unannounced visit was made on 19th May 2008. During the visits we: • • • • • • Talked with people who use the service, staff, the manager & visitors. Looked at information about the people who use the service & how well their needs are met, Looked at other records which must be kept, Checked that staff had the knowledge, skills & training to meet the needs of the people they care for, Looked around parts of the building to make sure it was clean, safe & comfortable, Checked what improvements had been made since the last visit. We told the manager what we found. What the service does well: Information about the service at West Lodge is written in a book called the Service User Guide. This clearly gives information about the service and has good photographs of different parts of the building so that people can see what it is like inside. Each person who lives at the home has a copy of this book in his or her care file. People are invited to look around the house before deciding to move in. This helps people to make an informed decision about where to live. West Lodge DS0000015758.V367751.R01.S.doc Version 5.2 Page 6 It is very comfortable inside West Lodge. There is good furniture and the rooms are nicely decorated. It is well looked after and kept very clean and tidy. The staff know the service users well and they are taught how to support and care for people with learning disabilities. This means that service users receive the right kind of support. The friendliness shown between service users and staff makes everyone visiting West Lodge feel very welcome. Service users said they are happy living here. One service user said: “This is a nice home, it is a nice place to live.” Relatives, when asked what they thought the home does well answered: “We are included well in the our X’s life and kept informed how they are doing.” “There is lots of activity going on an X is very happy.” Staff support service users to try different activities in the home and in the local community and as a result service users live a lifestyle that is interesting and varied. Service users are supported to develop as people with control over their lives. For example they are supported to look after themselves, be independent and develop relationships with other adult people. So that staff know how service users like to be supported with things that they cannot do themselves, service users and their families help staff to write down instructions for staff to follow. These are called care plans. Each service user has a care plan that has pictures and photographs to make it easier to understand what has been written about them. If a service user takes part in an activity that might present a risk the staff are given directions how to keep the person safe. Service users enjoy a good variety of food that is served to them in a way that they can manage and prefer. They are asked what sort of food they like and dislike and staff remember this when they support service users with the shopping and when they make choices. What has improved since the last inspection? The Statement of Purpose has been looked at to make sure that the information in it is correct and that a true description of the service, that is delivered and the people responsible for it, is described accurately. West Lodge DS0000015758.V367751.R01.S.doc Version 5.2 Page 7 The manager has now achieved the qualifications to prove that she is capable of doing her job properly. This means that service users, receive a service from a staff team that is lead in a way that empowers and supports service users well, and that they live in a home that is safe, comfortable and clean. New internal doors have been fitted that can be left open and that close automatically in response to the sound of the fire alarm. This means that service users can move freely around the home without the barriers of closed doors, while at the same time fire safety systems are in place that will help to protect them in the event of fire breaking out. New carpets have been laid throughout the home and new lounge furniture has added comfort for service users when relaxing at home. 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 summary of this inspection report can be made available in other formats on request. West Lodge DS0000015758.V367751.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 West Lodge DS0000015758.V367751.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. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good multidisciplinary preadmission assessments demonstrate service users’ needs and aspirations and assist the home to make informed judgements as to whether the needs can be met. EVIDENCE: The home receives a full assessment of need from the referring agency prior to anyone moving in. The home also has a comprehensive assessment process that is also carried out at this stage and both records are kept in individual service users’ care files. This information enables the service to make an informed decision as to whether they can meet the identified needs. All but one of the service users are very happy living at this home, one person said “This is my home and I love it,” however another service user said “I am not happy living here.” The manager is appropriately addressing this. A relative commented, “This home was the right thing for X.” “ I am very happy with the way things are.” West Lodge DS0000015758.V367751.R01.S.doc Version 5.2 Page 10 The assessment process is an ongoing process and the care plans reflect this. Assessed risks are also addressed in the care planning process. The care plans are regularly monitored and adapted to address changing needs and aspirations and this is particularly monitored for one service user who, for some time now, has clearly stated that they wish to move to another service. The contracting agency and the home have carried out detailed assessments and the service user has been supported through the person centred planning process with the outcome that alternative accommodation is needed. An alternative place to live has now been identified and a move in date is imminent. The home is working closely with the service user and so that a smooth transition process is achieved. Plans are also in place to work with the new staff team nearer to the transition date. The length of time that the service user has had to wait is now causing frustration and challenging behaviour is often displayed. Although detailed guidelines are in place for staff to follow in a consistent way, the home is finding it increasingly difficult to address the service users needs especially when such behaviours are demonstrated. Unfortunately this is having negative consequences on everyone who lives at the home. The manager is keeping regular contact with the Care Manager. West Lodge DS0000015758.V367751.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans, that are the outcome of ongoing assessment, guide staff to appropriately support service users’ care needs, promote their independence by safely addressing risks and enable staff to support service users to make choices about their lives. EVIDENCE: There is a care plan in place for each service user living at this home. The information recorded in them is current and clearly guides staff to effectively address the individual service users’ personal, social and emotional care needs. Service users are empowered to lead their care plans. They are written with a person centred approach and they are illustrated with pictures so that service users have access to what is written about them. West Lodge DS0000015758.V367751.R01.S.doc Version 5.2 Page 12 In addition to this and in an attempt to make the care plan accessible to the individual service user, a plan that is illustrated with photographs has also been developed. This very clearly informs the reader about the person, their needs, how they communicate, their preferences, important people and events in their lives and their aspirations. The photographs and pictures used clearly illustrate the printed words. A key worker system is in place that works effectively and gives consistency to service users. The manager stated that key workers and service users are matched sensitively for compatibility. Service users spoke positively about staff members in general and in particular their key worker. The key worker is responsible for making sure that the information recorded about individual service users is kept up to date. The key worker monitors the care plans monthly and annual reviews take place when people involved in service users’ lives are invited to discuss the plan of care in place and any other issues about the placement. One service user’s request not to have a designated key worker has been respected and the manager and staff in general monitor their needs. The manager and staff have worked hard to develop an effective care planning system. This is well organised and to make it easy to access information is divided into different files, for example there are separate Health, Support and Financial Plans. Service user’s individual goals and the action taken to achieve them are recorded in a separate file. When a goal is achieved it then becomes part of the daily routine for the person. All of the separate files are kept in individual plastic storage boxes with the photograph of the individual service user on the front. Risks are identified and addressed appropriately. Risk management plans are put in place to reduce the risk of harm to the service user and are an integral part of the care plan. West Lodge DS0000015758.V367751.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are supported to live appropriate and fulfilling lifestyles both in their own home and the local community, while at the same time they are supported to maintain relationships with family and friends. Furthermore meals are healthy, nutritious and attractive, and are prepared to meet service users’ individual dietary needs. EVIDENCE: All of the service users have individual weekly activity programmes that are recorded in their care plan. These are flexible but act as a structure to the individual’s week. The activities have been developed as the result of a process known as “Community Mapping” where service users’ individual likes and preferences are matched with different and varied facilities in the community. For example one service user who loves dancing and books now West Lodge DS0000015758.V367751.R01.S.doc Version 5.2 Page 14 visits the local disco and library where they are accommodating “talking books” for them. The likes and preferences are identified as part of the personal care planning process. Also as a result of using this process service users have chosen a variety of holiday destinations. Holidays this year have included visits to Great Yarmouth, Haggerston Castle, the Keilder Outdoor Centre where service users enjoyed activities such as canoeing and walking, Legoland and London. Service users discussed the holidays with enthusiasm. The home is run and organised to promote the recognition of respect, privacy and the rights of service users. Staffs working practices reflect this. Service users’ rooms are respected as their private space and service users move around the home with confidence, demonstrating ownership of their surroundings. One person keeps their room locked when out and was also proud to show that they have a key to the front door. The care plans record service users’ individual daily routines. They get up at their preferred time, sit where they choose and move around the home as they wish. One service user who previously enjoyed staying in their room now socialises more and enjoys sitting with others in the lounge. So that service users are supported to take control over their lives individual “diaries” identify different tasks, for which they are responsible. For example different appointments they need to attend, menus to be chosen and developed in preparation for the weekly shopping and accidents and incidents that need to be discussed and addressed. This has proved to be a successful process. Service users were aware of the order of their day and were able to discuss what activities were planned. One service user who was previously reluctant to take part in domestic chores now takes responsibility with certain tasks. Another who was finding it difficult to move into the adult world has registered with college to do courses in cookery and independent living. The progress of individual service users’ emotional and personal development is evident. Service users are now more confident to communicate with their peers and staff, as well as others in the community. One service user described how they are now an independent in traveller, owns a bus pass and also does a lot of walking, which they said, “Is helping me to keep my weight down.” West Lodge DS0000015758.V367751.R01.S.doc Version 5.2 Page 15 Everyone has recently become a member of the English Heritage and National Trust organisations and this has encouraged and facilitated individuals to visit a variety of places of interest. Family members visiting the home stated, “You can see big improvements in everyone who lives here.” “There have been major improvements in peoples’ lives.” “If there is anything going on in the home staff inform me and invite me.” “I am always made to feel welcome.” A varied nutritious menu is offered at the home that caters for individual preferences and needs. The home has been awarded the Healthy Home Award for the second year running. The award is promoted and assessed by Sunderland Council and Environmental Health and is open to all care services in the borough. Last year was the first time that the award had been given to a small home so everyone at West Lodge is particularly proud and delighted at receiving the award for a second year. Different standards are assessed including all aspects surrounding food and food allergies, menus and food handling as well as other issues such as the promotion of Equality and Diversity, Health and Safety and Training. West Lodge DS0000015758.V367751.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ personal and healthcare needs are met in a flexible but consistent manner, reflecting a healthy lifestyle. The medication arrangements in place are appropriate to the needs of service users and ensure their health and welfare. EVIDENCE: Service users are supported to register and attend healthcare practices in the local community. Visits to the GP, dentist’s, opticians and other healthcare professionals are recorded in individual care files, with the outcome of the visit. Staff from the home and healthcare specialists involved in the lives of individual service users work closely together, these include psychologists, physiotherapists, speech therapists dieticians and community psychiatric nurses. Healthcare needs are clearly recorded in Health Care Action Plans that are recorded together in one file. The staff and the manager feel that having all relevant information about a person’s healthcare needs together proves helpful West Lodge DS0000015758.V367751.R01.S.doc Version 5.2 Page 17 when service users attend healthcare appointments and in the event of a service user being admitted to hospital. Any health or behaviour changes that are observed are clearly recorded and if needed action is taken to gain specialist healthcare advice. The guidance given is recorded in the care plan. This is particularly evident in relation to challenging behaviours. Clear guidelines in one care plan, as advised by a psychologist, guides staff to appropriately support a service user in relation to this. The guidelines also support other service users and protect them from potential harm. Appropriate equipment is in place to reflect the assessed physical and personal needs of service users with physical disabilities. An overhead tracking system is fitted in the bathroom to provide safe and comfortable transfers via a hoist from chair to bath and a slide and glide chair provides transfers from chair to toilet. Such equipment and the procedures in place for its safe use protect and promote service users’ privacy and dignity. Staff support service users with their personal tasks in a discreet and respectful manner and are trained in all aspects of their individual healthcare needs. The home has an efficient medication policy supported by procedures and practice guidance, which staff understand and follow. Medication records are fully completed, contain required entries and are signed by appropriate staff. All staff have completed training regarding the safe administration of medication and the manager monitors compliance with the home’s procedures. One service user is appropriately supported to take control of their personal medicines. A risk assessment is in place regarding this. West Lodge DS0000015758.V367751.R01.S.doc Version 5.2 Page 18 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. 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. Arrangements are in place that help to protect service users from abuse and to seriously address complaints and concerns about the service. EVIDENCE: The home has a comprehensive complaints procedure that is in picture format in an attempt to make it more accessible to the service users. Staff are aware of signs given by service users when they are not happy or are showing concern about something. This is recorded in individual care files and acted upon. Staff have received training regarding the local authority’s Protection of Vulnerable Adults (POVA) procedures and are able to confirm the action they would take if an abusive incident was observed or reported to them. Staff are confident that staff who “blow the whistle” regarding bad practice are supported positively by the service. There have been two incidents that have resulted in the home making alerts to the local authority’s Safeguarding Adults Team. One was reported prior to the last inspection and the other earlier this year, both were addressed appropriately by the home. The second allegation was upheld and resulted in the home taking disciplinary action and dismissing two members of staff. Both incidents remain ongoing. West Lodge DS0000015758.V367751.R01.S.doc Version 5.2 Page 19 Staff have received training in relation to Verbal and Physical Aggression and are consistent in how challenging behaviour is to be approached. The approach is consistent with guidelines in individual care plans. There is a clear system in place for the recording of service users’ monies. Each service user has individual money zipped pockets and records and receipts of purchases reflect how money is spent. In addition to this each service user has a bank account where any money paid to them is deposited. Service users access this with support, all were aware of this practice, however one service user described how they access their own money independently. West Lodge DS0000015758.V367751.R01.S.doc Version 5.2 Page 20 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. 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. The home is homely, comfortable, clean and decorated and furnished to a high standard. It provides service users with spacious, private and communal spaces that are safe in which to live. EVIDENCE: The standard of the furnishings and fittings in this home are good presenting an attractive and comfortable environment for service users to live. The use of light coordinating colours for the decorating and furnishings has given a feeling of space and calmness. Service users sit in comfort in leather sofas and chairs recently new to the home and two service users who rely on wheelchairs for mobility are able to move around the ground floor independently and safely. West Lodge DS0000015758.V367751.R01.S.doc Version 5.2 Page 21 All service users have individual bedrooms that are decorated and furnished to reflect individual personalities. One service user listened to music in the privacy of their own room and was able to access the music centre and CDs with ease. The separate laundry is well furnished, with appropriate facilities and domestic machinery. The windows throughout the home including the laundry are fitted with restrictors. This means that the windows can now be left safely open when fresh air is needed or when service users choose. There are areas in the home that are showing signs of wear and tear, however a full redecoration programme is planned to commence throughout the home in the very near future. The home is well maintained and reflects effective cleaning routines. Staff have received training regarding infection control. The cleanliness of the home reflects this and also the good cleaning schedules in place. A patio door accessible to service users leads directly into the gardens from the eating area in the kitchen and these are kept neat and tidy. Currently there is much excitement in the home regarding the garden, as a community based group are currently planning a “makeover” to this area with the aim of developing a sensory garden where bushes and plants will be removed and replanted with scented plants. An attractive mural is to be painted on the wall and new garden furniture is to be bought. This will provide a much improved and stimulating area for service users to access. Plans are in place to include service users in the planting process. West Lodge DS0000015758.V367751.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 34,35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Robust recruitment & selection procedures and regular training opportunities ensure that service users are appropriately supported and protected by a competent and qualified staff team. EVIDENCE: The staff team is diverse in experience, skill and knowledge and sufficient in number to address the assessed needs of the service users. The number of staff on duty is dictated by the activities arranged for the day or evening, however there is never less than 3, but often 4 or 5 to each shift. As a team the staff are aware of the service’s goals and work enthusiastically towards meeting them. All of the staff spoken to stated that they were happy working at the home and found it a friendly and supportive place to work. West Lodge DS0000015758.V367751.R01.S.doc Version 5.2 Page 23 Comments include, “This is the best place I have ever worked.” “It is the cleanest and friendliest home I have worked in.” “The training has given me more confidence in my work, I am so happy here.” Service users and their relatives were very complimentary about the staff team and comments include:“Staff are very pleasant and helpful.” “I like the staff, they help me.” “I feel very safe with members of staff.” “They know the service users’ well and give them good support.” Staff are up to date with mandatory training and all staff are qualified in NVQ 2 and are now working towards NVQ 3. They share their knowledge with each other for the benefit of the service users and work effectively as a team transferring their knowledge to their work practice. Recent training includes the safe handling of medication, ageing and learning disabilities, mental health awareness and equality and diversity. In addition to this some staff have attended training regarding the Mental Capacity Act. The home follows the company’s robust recruitment procedures and staff files include, completed application forms, 2 references and satisfactory CRB checks. West Lodge DS0000015758.V367751.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The manager, who is well supported by her staff team, provides excellent leadership and runs a service that has effective monitoring systems that are focussed on the best interests of the service users. EVIDENCE: The manager has worked at this home since January 2006. She is registered with CSCI (Commission with Social Care Inspection) and is now fully qualified having recently achieved the Registered Managers Award (RMA) and NVQ4 in Care. The manager is a facilitator for both Moving and Handling and Person Centred Planning, and has attended training regarding Equality and Diversity, Mental West Lodge DS0000015758.V367751.R01.S.doc Version 5.2 Page 25 Capacity Part 2, Supervision and Appraisal and Budget Management. She has recently attended training regarding the Administration of Medication level 3 and plans to go on to do the Management of Medication level 4, mandatory training is also up to date. The manager interacts with service users and staff positively and in a supportive way. Staff feel well supported by their manager and could go to her for guidance and advice when needed. One said, “The manager is spot on, she wouldn’t ask you to do anything different to what she would do herself.” “She works well with her team and keeps us focussed.” The manager has an innovative approach to managing the service by finding different ways to motivate, develop and measure the effectiveness of the staff team. The manager and staff work together with service users to establish a good working ethos in the home. Policies and procedures are regularly reviewed to ensure that they are appropriate to the needs of the service users. A diagram on the wall of the home identifies the service plan for the year illustrating how the aims and objectives for the year are to be met in the form of a “pathway”. As objectives are accomplished this is mapped on the path. This is a good way to keep service users and staff involved in and informed about how the aims and objectives of the yearly plan are accomplished. The policies and procedures are regularly reviewed and brought up to date when necessary. They are discussed in staff meetings and staff are monitored as to their understanding of them through the development of questions and quizzes. The last staff meeting minutes recorded that the whistle blowing and grievance procedures were brought to staffs’ attention in this way. Other meetings discussed the management of bullying, racial and sexual harassment and health and safety procedures when on holiday. The manager keeps up to date with changes in legislation, new ideas and policies regarding working with people with learning disabilities, by accessing the websites of Valuing People Now, The Department of Health and CSCI. This information is then shared with staff. There is a good quality assurance system in place the outcomes of which are recorded. The system is monitored internally monthly by the manager and annually by an external person. This ensures that the home’s policies and procedures are put into practice and that the service is led in the best interests of the service users. West Lodge DS0000015758.V367751.R01.S.doc Version 5.2 Page 26 Completed surveys inform the manager of the service users and their relatives/advocates service satisfaction. Risks identified throughout the home are monitored and addressed well. West Lodge DS0000015758.V367751.R01.S.doc Version 5.2 Page 27 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 3 3 2 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 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 X 33 4 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 4 X 4 X X 3 X West Lodge DS0000015758.V367751.R01.S.doc Version 5.2 Page 28 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 YA3 Regulation 12(1) Requirement The registered manager must ensure that: • Service users’ assessed and changing needs and aspirations are met. • The home is able to demonstrate the capacity to meet service users’ needs. Timescale for action 30/09/08 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 YA24 Good Practice Recommendations It is recommended that the plans in place to decorate the home throughout go ahead, so that the décor of the home maintains the high standards set and maintained throughout this service. West Lodge DS0000015758.V367751.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 West Lodge DS0000015758.V367751.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. 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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