Care Home: Approach Lodge

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What the care home does well The service has a demonstrable commitment to provide proactive and supportive rehabilitation to people experiencing mental illness. The Registered Manager demonstrated energy and dedication to service development, and had sound insight into the needs of the people who use or prospectively use the service. This was mirrored by the solid preliminary work done in setting up the service by the Registered Person and the owner. There is very good information available to prospective residents and referrers about the service. The assessment procedure is excellent and takes into consideration the equality and diversity needs of prospective residents. The home is comfortable, well resourced and refurbished to a very high standard. What has improved since the last inspection? This is the first inspection. What the care home could do better: The Equal Opportunities Policy and Statement of Purpose need updating to reflect current legislation. The relationships policy and procedure needs expanding. Further information on the health status of one resident must be obtained. A child protection policy and procedure must be put in place to protect any children visiting the home and the adult protection policy and procedure simplified.Staffing levels must be kept under review once the home is fully occupied to ensure that all residents` needs are met. CSCI must be informed of the outcomes of these reviews and staff changes. All staff, including the Registered Manager, must receive alcohol and drug training, learning disabilities training and further in-depth training on mental health issues. It is also recommended that the infection control policy and procedure be reviewed. CARE HOME ADULTS 18-65 Approach Lodge 2 Approach Road London E2 9LY Lead Inspector Margaret Flaws Unannounced Inspection 17th October 2007 10:00 Approach Lodge DS0000069625.V352281.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 Approach Lodge DS0000069625.V352281.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. Approach Lodge DS0000069625.V352281.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Approach Lodge Address 2 Approach Road London E2 9LY 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) 020 8981 2210 020 8981 2210 care@approachlodge.co.uk Approach Lodge Ltd Michelle Maxine Wimpress Care Home 7 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (7) of places Approach Lodge DS0000069625.V352281.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following category of service only: 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 categories: 2. Mental Disorder, excluding Learning Disability or Dementia - Code MD The maximum number of service users who can be accommodated is: 7 Date of last inspection Brief Description of the Service: The home is located in a refurbished Victorian house at the convergence of two roads in Bethnal Green. It is laid out over four floors, with a small paved area at the front and yard with a smoking gazebo at the back. CCTV cameras protect the premises. It has seven bedrooms, lounge, kitchen, laundry, visitors room, office and one small room for staff to use. The house is close to local shops and within walking distance of Bethnal Green shops and the Roman Road market. Public transport access is good, with bus routes and Bethnal Green tube and rail station close by. The home is intended to provide medium term rehabilitation support for people with mental disorder so that they can eventually move in to supported living or independent accommodation. Fees for the home are £1050 per week. Approach Lodge DS0000069625.V352281.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This first inspection took place over one day and the Registered Manager assisted me throughout. I spoke to all the people currently living in the home and to three staff members. I distributed several surveys for relatives and heath professionals but at the time of writing, none have been returned. After a tour of the premises, I inspected the home’s policies and procedures; all care and staff records, health and safety files, other home records and preregistration correspondence. The home also provided CSCI with an Annual Quality Assurance Assessment, which added good quality information to the inspection. What the service does well: What has improved since the last inspection? What they could do better: The Equal Opportunities Policy and Statement of Purpose need updating to reflect current legislation. The relationships policy and procedure needs expanding. Further information on the health status of one resident must be obtained. A child protection policy and procedure must be put in place to protect any children visiting the home and the adult protection policy and procedure simplified. Approach Lodge DS0000069625.V352281.R01.S.doc Version 5.2 Page 6 Staffing levels must be kept under review once the home is fully occupied to ensure that all residents’ needs are met. CSCI must be informed of the outcomes of these reviews and staff changes. All staff, including the Registered Manager, must receive alcohol and drug training, learning disabilities training and further in-depth training on mental health issues. It is also recommended that the infection control policy and procedure be reviewed. 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. Approach Lodge DS0000069625.V352281.R01.S.doc Version 5.2 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 Approach Lodge DS0000069625.V352281.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. The assessment procedure is excellent and takes into consideration the equality and diversity and cultural needs of prospective residents. The service has a demonstrable commitment to proactive and supportive rehabilitation for people experiencing mental illness, providing good information on the service and a comprehensive assessment to start the process. EVIDENCE: At the time of this first inspection, there were three people living in the home, all of whom had moved in over the past two months. The home has very good information for prospective residents, including a good website (www.approachlodge.co.uk), brochure, Service User Guide and Statement of Purpose. The Statement of Purpose (and the Equal Opportunities Policy) needs updating to refer to and reflect current equality legislation. New legislation has been put in place since the document was written. Approach Lodge has a clear and comprehensive assessment procedure. Four prospective residents have been assessed and are likely to move in over the next few weeks. I checked the assessments for the prospective residents and the assessments of the current residents. The assessment process involves a series of documented meetings between each prospective resident, a range of Approach Lodge DS0000069625.V352281.R01.S.doc Version 5.2 Page 9 professionals and the Approach Lodge Registered Manager and Registered Person. The Placing Authorities also provide comprehensive assessments. Approach Lodge has two main assessment forms – a functional assessment and a referral assessment, which are completed by the Registered Manager and the Registered Person. These are available for prospective residents and referrers to read on the home’s website. Some prospective residents are from East Africa and their mental heath status has been affected by the use of a drug common to that region. The Registered Manager described to me how she was consulting with culturally appropriate mental health services to support these prospective residents and said that it is likely that this support and advice will be extended to staff when the residents move into the home. It is likely that, when fully occupied, the home will have a diverse cultural mix of Bengali, Afro-Caribbean, Somali and mixed black British residents, and a good mix of ages and genders. The Registered Manager described how she is working to match the cultural and linguistic backgrounds of staff and residents. This appeared a thoughtful and considered process, supported by the thorough assessments I read and the recruitment procedure (described under ‘Staffing’). The Statement of Purpose, Service Users’ Guide and the home’s website are specific about which needs the home believes it can reasonably meet. A copy of the Service Users’ Guide is placed in each person’s bedroom. Prospective residents are offered a trial stay of one to three months. The three residents I spoke to said that they had had an initial stay to see if the home suited their needs. They all said that they were happy to continue living at Approach Lodge. They had all come back to the area, their locality, after being placed in another part of London. Everyone had a clear contract from placing authorities on file. Approach Lodge DS0000069625.V352281.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People living in the home have their needs assessed and goals discussed and recorded in a regularly reviewed individual plan. They are supported to make decisions about their lives in line with their wishes and the rehabilitative philosophy of the home. Risks are assessed and discussed on an individual basis and the residents’ finances protected. EVIDENCE: The stated goal of the service outlined on the website is to: “promote the independence of the service users through Person Centred Planning to assist in their rehabilitation and encourage autonomy within the local community to develop the confidence needed for them to move on from 24 hour care to independent living”. I read the files of all people living at Approach Lodge. Each person has a care plan written to address their assessed and changing needs, their wishes and Approach Lodge DS0000069625.V352281.R01.S.doc Version 5.2 Page 11 views. These person centred plans support the home’s rehabilitative ethos (outlined in the Statement of Purpose and Service User Guide) by identifying individuals needs and goals and outlining how these could be met. The plans inspected were clear and specific. They provide practical support to help residents develop their living skills to move on from long or acute periods of hospitalisation towards independent community living. Staff have received training in writing person centred care plans. Each person’s care plan is reviewed in an Individual Progress Review each month or more frequently, if necessary. Although the residents were relatively new to the home, their care had been reviewed and changes documented regularly. Each individual signed the review. The home operates a key worker system and the residents I spoke to were positive about their key workers. One said that she had a very good affinity with her key worker and felt very supported by her. There is also a back-up key worker to cover when the lead key worker is off duty. Residents also said that they have input into the selection of their own key worker and that they were able to choose what they do, with support as they identify they need it. There is a risk assessment policy and procedure, which covers both environmental and individual risks. The home writes each risk assessment around individual needs. For example, the risks each person might face using the spiral staircase to the lower ground floor were assessed individually. The home is situated in an area where street drug dealing is commonplace. To protect residents who may be vulnerable, there are clear risk assessments and guidelines for staff about how to maintain the safety of the residents who go for a cigarette either on the front door step or in the ‘smoking gazebo’ at the back of the property. One staff member regularly sat with a resident while she had a cigarette and chatted with her. Other risk assessments sampled covered kitchen knives (locked away), cooking and supporting residents to go out into the community on their own. I observed a good procedure for handover between staff shifts and good documentation (a well maintained handover diary) to support this. This meant that the daily changing needs of the residents could be conveyed well across the team. There is a good policy and procedure for protecting the residents’ finances. Each bedroom has a small locked safe used by people who maintain their own finances. There is also a locked cupboard in the office for safekeeping resident’s money and a financial handover log which is checked and signed on each shift. The home is committed to working with individuals if they need to learn to budget their finances prior to moving to independent living. An example of this is food management (Standard Fifteen). Approach Lodge DS0000069625.V352281.R01.S.doc Version 5.2 Page 12 Approach Lodge DS0000069625.V352281.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, 14,15,16,17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People living in the home can be confident that they will be supported in their rehabilitation through pursuing activities and leisure of their choice; through access to the local community and to relationships. However, the relationships policy would benefit from expansion to better consider their needs. They can generally be confident that their rights and responsibilities will be recognised. Food in the home is very good. EVIDENCE: Individually tailored and chosen activities form the backbone of the home’s rehabilitative programme. These include involvement in the day to day running of the home. On the day of the inspection, two residents were at home and one came back from hospital for a visit, accompanied by a key worker. Approach Lodge DS0000069625.V352281.R01.S.doc Version 5.2 Page 14 One staff member, who has worked in similar residential settings, acts as an Activities Coordinator. He spends time with each resident and talks to their key worker about activities they enjoy. He then builds up an activities plan with the person and the keyworker. Examples of individual activities include going to the gym, swimming, Turkish baths, church attendance and visits to a local day centre. At the first residents’ meeting, residents requested magazines, newspapers and access to the Bethnal Green library close by. The home has responded to these requests and initiated weekly discussions on reading topics. The home runs two hour sessions each week for the residents on topics such as mental health awareness, and medication awareness and management. The home has digital television and provides internet access for the residents. Family involvement is encouraged and supported through the visitors’ policy and procedure. As the current residents are local to the area, some have families close by who visit very regularly. The home also has a policy and procedure covering relationships but at present, this only applies to maintaining professional boundaries between staff and residents. It is important, in recognising residents’ rights, that this be reviewed to include residents’ relationships with each other and with other people. A requirement is made for this to be expanded. I observed the staff knocking on the doors of residents’ rooms and generally respecting their wishes and their privacy. When I arrived at the home unannounced, the Registered Manager had just returned from shopping. I observed that the food purchased was of very good quality. At their recent meeting, residents gave positive feedback on the food. They choose their menus every few days. The Manager said that they were now starting to do the shopping on the internet, because this enabled the residents to see the food online, make up a virtual shopping basket and understand the management of the food budget. I checked all the cupboards and the fridge and freezer. There was an excellent range of fresh fruit and vegetables, meat, fish and other ingredients for healthy meals. There was also a freshly baked tray of biscuits. The residents participate in cooking and sometimes make their own meals. Cultural needs and individual preferences are assessed and catered for (eg. whether the person requires halal or vegetarian food). Fridge and freezer temperatures were monitored and recorded daily. Approach Lodge DS0000069625.V352281.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20,21 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The physical and emotional needs of people living in the home are assessed and met in their interests. Personal support tends to be of a prompting nature. Wishes in case of death are recorded. Residents are protected by the home’s medication policies and procedures. EVIDENCE: The Registered Manager showed me the database system used to maintain communications and records for the residents, including healthcare records. This appeared a simple but well structured way of monitoring the residents’ needs and ensuring that they are met. Regular healthcare appointments, meetings and case conferences are managed on this database. In addition to the mental health needs of the residents (which are assessed and reviewed by the mental health support teams), physical health issues managed in the home include diabetes and physical disability. Specific needs were appropriately documented in residents’ files, with clear guidelines for staff to follow. In discussion with the Manager, it became clear that one person’s health information needed clarifying. The home has tried to get this Approach Lodge DS0000069625.V352281.R01.S.doc Version 5.2 Page 16 information from previous GPs without success. A requirement is given that this information be obtained as soon as possible. Support provided is more of a prompting nature or is emotional support rather than actual physical personal support. For example, excellent emotional support was being provided to one person who had recently had a baby. This was observed in the interactions of staff with the resident throughout the day. The home has a clear medication policy and procedure and staff have been trained in this area. Boots Chemist provides a full medication service to the home and medication is delivered in blister packs weekly. I checked the medication stock and Medication Administration Record with the Registered Manager. At the time of the inspection, medication was only held for one person, because one resident was in hospital and another self-medicates. The medication was appropriately stored and the MAR sheet was in order. A controlled drug was correctly stored. There was a risk assessment completed for the resident who self medicates and all residents have a locker in their bedrooms for the safe storage of medication. Wishes in case of death were recorded in each person’s files, after discussion with them. Approach Lodge DS0000069625.V352281.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. 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. People living in the home are generally protected by good complaint and adult protection policies and procedures and by staff trained to use them. Child visitors would benefit from a child protection policy and procedure. EVIDENCE: The complaints, comments and comments policy and procedure in written in plain English and gives clear guidance to people who wish to use it. It is in the Service User Guide (in each person’s room) and on the website. No complaints have been received at this stage. I checked the training records. Staff have been trained in adult protection. They confirmed this in my interviews with them and were able describe what they would do in instances of suspected abuse. The home has an adult protection policy to safeguard the adults in the home, but it is quite long and cumbersome. It is recommended that a simplified version be produced. There is a copy of Tower Hamlets Adult Protection policy and procedure available in the home. Also, because there are likely to be child visitors, the home must produce its own child protection policy and procedure to protect them. Approach Lodge DS0000069625.V352281.R01.S.doc Version 5.2 Page 18 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, 25, 26, 27, 28, 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 refurbished to a very high standard to provide an excellent environment for the residents to live in. Security features have been incorporated into the home to protect the residents. The home is kept clean and hygienic. EVIDENCE: The house has been refurbished and furnished to a high standard. The bedrooms, although small in some cases, are well laid out, with good ensuite facilities. The lounge area is comfortably furnished. One resident said, “I’ve stayed in some real dumps but this certainly isn’t one.” The building is laid out over four floors, with the kitchen, communal lounge, laundry and one bedroom on the lower ground floor and bedrooms and the office on the upper floors. There is a small room on the top floor for the staff to use. There is a simple system for recording and fixing maintenance problems. Approach Lodge DS0000069625.V352281.R01.S.doc Version 5.2 Page 19 All staff, assisted by the residents, do the cleaning daily and there is a cleaning schedule. Security in the home has been well thought through. For example, there is a buzzer, which sounds whenever someone goes out or comes in the main door. There is a CCTV system, with monitors in the Approach Lodge office and in the offices of the Registered Person and the owner. This provides an unusual degree of back-up to the staff on duty from the Senior Management. In the laundry, the washing machine is capable of temperatures of up to ninety degrees, ensuring good infection control of soiled items. There are locked COSHH cupboards and sensible procedures for managing dangerous chemicals in the home. The home has an infection policy and procedure but this needs a minor review. A recommendation is made. Approach Lodge DS0000069625.V352281.R01.S.doc Version 5.2 Page 20 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): 32,34,35,36 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People living in the home are protected by appropriate recruitment procedures and supported by generally well trained and supervised staff. They would benefit further as the staff training and knowledge base is expanded. At the time of the inspection, sufficient staff were on duty to meet the needs of the people living in the home but staffing will need to be increased as the occupancy moves to capacity. EVIDENCE: The home has a clear recruitment policy and procedure. The procedure has been followed in the recruitment of new staff for the home, with a clear audit trail in the seven staff files I checked. Staff confirmed how they had been recruited in line with the procedure. In order to get a good mix of skills on the team, the home has targeted students completing degrees in related areas and professionally qualified people. There is a two stage interview process and the Registered Manager, the Registered Person and a resident interview prospective staff. All pre-employment checks, including Criminal Records Bureau and reference checks, had been completed prior to employment and Approach Lodge DS0000069625.V352281.R01.S.doc Version 5.2 Page 21 new staff confirmed that they were fully inducted using the Skills for Care Foundation model. The multicultural staff team reflects the culturally diverse area of Bethnal Green and the cultural backgrounds of the residents. The team has an excellent balance in terms of age, ethnicity and cultural background, religious belief and gender. There is a small room for the staff to use at night. The Registered Manager said that, when the home is up to full occupancy, the staffing levels, including day staffing, ratios at night and the waking/sleeping night staff balance, will be reviewed and increased. A requirement is given that staffing levels are reviewed and CSCI informed of any changes. I checked the staff training files. They have been trained in the core competencies needed to run the service including adult protection, health and safety, food hygiene, infection control, medication, dealing with aggression and challenging behaviour, person centred planning, recording and report writing, COSHH and basic mental health awareness. The AQAA stated that six out of nine staff (66 ) have NVQ qualifications in care or are working towards them. The Registered Person is a consultant and trainer in the area of social care and is able to provide some training to the team. Training gaps were identified in the following areas and a requirement is given that staff be trained to work with people with learning disabilities, alcohol and drug addictions and receive further, ongoing training on mental health issues. This is should continue to be at a more advanced level for the Registered Manager. A process for staff supervision is in place and supervisions have commenced. These are documented in each staff member’s file and staff I spoke to confirmed that meeting with the manager monthly for supervision was a useful tool to help them develop their professional practice. Staff have also attended a course on ‘Supervision for Supervisees’. Residents were positive about the support they received from the staff. For example, one person said “They’ve got time for me. They don’t just stay in the office. They listen to me” Approach Lodge DS0000069625.V352281.R01.S.doc Version 5.2 Page 22 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 and 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People living in the home benefit from committed, pragmatic and resourceful management. They can be confident that they will be consulted on the running of the home and that their health and safety will be protected. EVIDENCE: Throughout the inspection, the Registered Manager demonstrated energy and dedication to service development, and sound insight into the needs of the people who do and prospectively use the service. This was mirrored by the preliminary work she did in setting up the service, alongside her line manager, (the Registered Person) and the owner. She was able to describe the value of the line management support she receives. Staff were very positive about the manager and management of the home (one said the manager provided “firm but kind management”) and said that they were pleased to be working in a Approach Lodge DS0000069625.V352281.R01.S.doc Version 5.2 Page 23 well run, well resourced and supportive environment. The residents echoed these statements. The Registered Manager is completing an NVQ 4 in care before enrolling in a Registered Manager’s Award. She has also completed basic mental health training but, along with the team, would benefit from further training in this area. A requirement is given under Standard Thirty Five. I discussed the home’s budget with the owner. It was clear that he had sound understanding of the need to resource the project well and expand the expenditure appropriately as occupancy increases. The home has a framework in place for quality assurance. The first residents’ meeting took place in September, chaired by one of the residents. According to the AQAA, issues discussed included food, following up resident’s leisure interests, settling into the home and establishing a routine. More formal consultation will take place after the home is more established. The Registered Manager sent CSCI a clear Regulation 37 report when one person was admitted to hospital and the Registered Person has undertaken her first formal inspections to report to CSCI (under NMS Regulation 26). I checked health and safety certificates on site. These certificates covered gas safety, electrical installation and portable appliances, fire alarms, water and were up to date and in order. The home has a sound fire policy and procedure; staff are trained in this area; fire checks take place and are recorded weekly; fire drills carried out and the home has a fire risk assessment. Approach Lodge DS0000069625.V352281.R01.S.doc Version 5.2 Page 24 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 4 2 3 3 3 4 3 5 3 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 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 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 3 13 3 14 3 15 2 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 3 3 X 3 X X 3 X Approach Lodge DS0000069625.V352281.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No (first inspection) STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation 6(a); 12(4) Requirement The Registered Persons must include current equality legislation in the Statement of Purpose and the Equal Opportunities Policy. The Registered Person must ensure that the Relationships Policy is expanded to cover residents’ relationships with each other and others. The Registered Person must obtain health information about one resident. The Registered Person must ensure that the adult protection policy and procedure is simplified. The Registered Person must ensure that a child protection policy and procedure is produced. The Registered Person must ensure that staff are trained in the following areas: • Learning disability • Mental health (ongoing) • Alcohol and drug problems Mental health training for the Registered Manager must be at Approach Lodge DS0000069625.V352281.R01.S.doc Version 5.2 Page 26 Timescale for action 31/12/07 2 YA16 12(2); 16(2) 31/12/07 3 4 YA19 12(1) 12(1) 31/12/07 30/01/08 YA23 5 YA23 12(1) 30/01/08 6 YA35 18(1) 30/01/08 7 YA33 18(1) higher level than for the other staff. The Registered Person must ensure that staffing levels are kept under review and increased proportionate to the occupancy of the home. CSCI must be kept informed of any changes. 15/12/07 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 YA30 Good Practice Recommendations The Registered Person should review the infection control policy and procedure. Approach Lodge DS0000069625.V352281.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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 Approach Lodge DS0000069625.V352281.R01.S.doc Version 5.2 Page 28 - 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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