Care Home: Chatsworth Care - Tudor Lodge

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What the care home does well Prospective residents are being provided with the information they require, in order to make an informed choice as to where to live. The information is being provided in an appropriate format for individuals who have severe communication difficulties. Prospective residents have the opportunity to visit and stay overnight, before deciding whether the home is likely to meet their needs. The home is able to demonstrate that it has the capacity to meet individuals` assessed needs. Their health, personal and social care needs are set out in an individual person-centred plan of care, and are being reviewed. Residents are having their health, personal and social care needs set out in an individual plan of care, and are being fully involved in the process of review and care planning. Chatsworth Care - Tudor Lodge DS0000068330.V361306.R01.S.doc Version 5.2 Page 8Residents are being assisted to participate fully in the day-to-day life and routines of the home, and are supported by staff in making decisions for themselves in their daily activities. Residents are being consulted regarding their views of issues that individually and collectively affect their lives within the home. Residents are being thoroughly assessed regarding potential risks to their health and safety, and are being enabled to take responsible risks wherever possible. Residents are being encouraged and enabled to develop personal and independent living skills, and have opportunities for accessing appropriate education, training and work experience. Residents are being provided with a wide and varied range of opportunities for participating in recreational and leisure activities, and have extensive contact and links with the local community. The home actively encourages residents to maintain family links and friendships both inside and outside of the home. Residents` rights and responsibilities are being recognised in their daily lives. Individuals are being enabled to be as independent as possible within the constraints associated with their disabilities. Residents` privacy is being respected. Residents are being offered a nutritious and healthy diet in a congenial environment. Residents` personal support and health care needs are being well met in this home, with support being planned and tailored according to the individual needs presented. The home has an appropriate and well-publicised complaints policy and procedure in place. Clear information for raising complaints is made available, and residents and their relatives/friends are encouraged to raise any concerns that they may have. The home`s policies, procedures, training and practice indicate that residents are being fully protected from abuse and are living in a safe environment. All staff attend statutory vulnerable adult training. Residents live in an environment, which is safe, well maintained and adapted for people with disabilities. Users have access to sufficient and comfortable communal facilities.Residents` rooms are safe, comfortable and pleasantly decorated, reflecting service users` personal identities, and being suited to their individual needs. Residents` toilets and bathrooms provide sufficient privacy and meet individual needs. The home presents as being clean and hygienic, and as a pleasant and homely environment in which to live. Staff have clearly defined roles and responsibilities, and are sufficient in numbers to meet service users` needs. Residents are having their needs well met by an appropriately trained and qualified staff group. Residents are being protected by appropriate recruitment policy and procedures. The home is being run competently, and in the best interests of the home`s residents. Residents` rights and best interests are being safeguarded by the home`s record keeping, and by its policies and procedures. The health, safety and welfare of residents and staff are being appropriately promoted and protected. What has improved since the last inspection? Each individual has been provided with a service user agreement. These have been prepared in a format that is appropriate to the communication needs of this user group. Residents are being fully protected by the home`s medication policy, procedures and practice. All staff have now undertaken accredited medication training. The home has developed its quality assurance processes, and is obtaining the views of residents, relatives and professionals. What the care home could do better: Generally, residents are benefiting from staff who are being well-supported. However, staff are not presently receiving sufficiently regular supervision.0 CARE HOME ADULTS 18-65 Chatsworth Care - Tudor Lodge 45 The Gallop Sutton Surrey SM2 5RY Lead Inspector Peter Stanley Key Unannounced Inspection 3rd April 2008 10:00 Chatsworth Care - Tudor Lodge DS0000068330.V361306.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 Chatsworth Care - Tudor Lodge DS0000068330.V361306.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. Chatsworth Care - Tudor Lodge DS0000068330.V361306.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chatsworth Care - Tudor Lodge Address 45 The Gallop Sutton Surrey SM2 5RY 020 8239 0814 020 8335 3264 kerrie.r@chatsworthcare.com 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) Gabrielle Anne Smith Graham Peter Smith Kerrie Louise Roach Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Chatsworth Care - Tudor Lodge DS0000068330.V361306.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following categories 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. Learning Disability - Code LD The maximum number of service users who can be accommodated is: 6 Date of last inspection Brief Description of the Service: Tudor Lodge was registered on 6 November 2006 and was inspected for the first time by the CSCI on 12 April 2007. The home is an attractive doublefronted detached property, and is situated in a very pleasant residential road within a desirable and expensive area of Sutton. The house has been converted into a residential home for up to six young adults with moderate to severe learning disabilities, challenging behaviour, complex needs and autism. The home aims to provide a supportive, enabling and homely environment for its residents. The house has three floors, with three bedrooms on the ground floor, two bedrooms on the first floor and one bedroom on the second floor. All bedrooms have an en-suite bathroom or shower, depending on the client’s choice and availability. There is a visitor/staff toilet on the ground floor and a large visitor/staff bathroom on the first floor. The bedroom on the second floor has a separate bathroom across the corridor, which is for the service user’s own exclusive use. There is a visitor/staff toilet on the ground floor and a large visitor/staff bathroom on the first floor. All windows in the home have been fitted with window restrictors. The home also has two separate toilets for service users, and another toilet for the use of staff. The home has two large lounges, a conservatory, which overlooks the patio and garden, and a large kitchen/dining area. There is a large, attractive back garden, and at the front of the property there is provision for some off-street parking. Access to the Chatsworth Care - Tudor Lodge DS0000068330.V361306.R01.S.doc Version 5.2 Page 5 garden is possible via the kitchen or through patio doors from the lounge. Chatsworth Care - Tudor Lodge DS0000068330.V361306.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 stars. This means the people who use this service experience excellent quality outcomes. This key inspection took place on 12th April 2007, and lasted about six hours. The inspection involved discussion with the registered manager, Kerrie Roach, and with the training manager, Chris East, the deputy manager and other staff members who were on duty. There are currently five residents, who range in age from 18 to 25. The inspector had wide-ranging discussion regarding the home and its day-to-day running, and examined service user and staff records, and other documentation relating to the management of the home. Information was also available from the Annual Quality Assurance Assessment (AQAA), which is completed by the home’s manager. As part of the inspection, an inspection of the premises was completed, and checks on health and safety certification were completed. The inspector received completed questionnaires from two relatives and one resident, and contacted two other relatives by phone. The feedback received was generally very positive, with very favourable comments being made about the home and the support being provided. Since the last key inspection there has been one new admission. The inspector has met the individual, who has settled well, and has examined documentation relating to the admission. This evidenced that detailed assessments and risk assessments have been completed, and that a person centred care plan had been put in place. Assessments and care plans are being completed to a high standard. All documentation examined was satisfactory and well maintained and in compliance with the national minimum care standards. The inspector was, once again, impressed with the knowledge and understanding displayed by the registered manager. The inspector observed good staff interaction and an enabling and person-centred approach in addressing the complex and challenging needs presented by an individual resident. The home has a wide-ranging programme of activities, which are tailored to individual needs, and is providing varied opportunities for enabling the development of individual abilities and potential. Individuals’ daily programmes are devised with their help and reflect individual choices and interests. On the basis of this inspection, and previous inspections, and the feedback received from relatives, the inspector finds that the home has continued to progress well, and that it is providing a generally excellent service. There is evidence of an inclusive, homely and enabling environment, with positive outcomes being achieved for individual residents. Chatsworth Care - Tudor Lodge DS0000068330.V361306.R01.S.doc Version 5.2 Page 7 Feedback obtained from questionnaires, phone sampling and review minutes indicates that the home is held in high regard and that the interests of residents are being generally well served. The home’s providers and management have demonstrated that they are fully committed to raising standards further through the development of best practice, the commitment to training, and the achievement of NAS (National Autistic Society) accreditation and Investors in People. There is just one requirement. This relates to the need for more frequent supervision of staff, this being evidenced to have significantly fallen off since the last inspection. Supervision must take place on at least a two-monthly basis, or ‘six times a year’ (standard 36.4). The support provided to staff is, however, generally very good, with evidence of good management-staff relationships, a very well developed training programme and a comprehensive annual appraisal of staff’s training and development needs. There have been training sessions arranged for autism awareness, the challenges of autism, and meeting the challenges of autism. Specialised training is being developed so as to provide further support for staff, particularly in relation to the core and specialist standards for autism spectrum conditions. The inspector would like to extend his thanks to the manager, Kerrie Roach, and the training manager, Chris East, for their assistance in helping to facilitate this inspection. What the service does well: Prospective residents are being provided with the information they require, in order to make an informed choice as to where to live. The information is being provided in an appropriate format for individuals who have severe communication difficulties. Prospective residents have the opportunity to visit and stay overnight, before deciding whether the home is likely to meet their needs. The home is able to demonstrate that it has the capacity to meet individuals’ assessed needs. Their health, personal and social care needs are set out in an individual person-centred plan of care, and are being reviewed. Residents are having their health, personal and social care needs set out in an individual plan of care, and are being fully involved in the process of review and care planning. Chatsworth Care - Tudor Lodge DS0000068330.V361306.R01.S.doc Version 5.2 Page 8 Residents are being assisted to participate fully in the day-to-day life and routines of the home, and are supported by staff in making decisions for themselves in their daily activities. Residents are being consulted regarding their views of issues that individually and collectively affect their lives within the home. Residents are being thoroughly assessed regarding potential risks to their health and safety, and are being enabled to take responsible risks wherever possible. Residents are being encouraged and enabled to develop personal and independent living skills, and have opportunities for accessing appropriate education, training and work experience. Residents are being provided with a wide and varied range of opportunities for participating in recreational and leisure activities, and have extensive contact and links with the local community. The home actively encourages residents to maintain family links and friendships both inside and outside of the home. Residents’ rights and responsibilities are being recognised in their daily lives. Individuals are being enabled to be as independent as possible within the constraints associated with their disabilities. Residents’ privacy is being respected. Residents are being offered a nutritious and healthy diet in a congenial environment. Residents’ personal support and health care needs are being well met in this home, with support being planned and tailored according to the individual needs presented. The home has an appropriate and well-publicised complaints policy and procedure in place. Clear information for raising complaints is made available, and residents and their relatives/friends are encouraged to raise any concerns that they may have. The home’s policies, procedures, training and practice indicate that residents are being fully protected from abuse and are living in a safe environment. All staff attend statutory vulnerable adult training. Residents live in an environment, which is safe, well maintained and adapted for people with disabilities. Users have access to sufficient and comfortable communal facilities. Chatsworth Care - Tudor Lodge DS0000068330.V361306.R01.S.doc Version 5.2 Page 9 Residents’ rooms are safe, comfortable and pleasantly decorated, reflecting service users’ personal identities, and being suited to their individual needs. Residents’ toilets and bathrooms provide sufficient privacy and meet individual needs. The home presents as being clean and hygienic, and as a pleasant and homely environment in which to live. Staff have clearly defined roles and responsibilities, and are sufficient in numbers to meet service users’ needs. Residents are having their needs well met by an appropriately trained and qualified staff group. Residents are being protected by appropriate recruitment policy and procedures. The home is being run competently, and in the best interests of the home’s residents. Residents’ rights and best interests are being safeguarded by the home’s record keeping, and by its policies and procedures. The health, safety and welfare of residents and staff are being appropriately promoted and protected. What has improved since the last inspection? What they could do better: Generally, residents are benefiting from staff who are being well-supported. However, staff are not presently receiving sufficiently regular supervision. Chatsworth Care - Tudor Lodge DS0000068330.V361306.R01.S.doc Version 5.2 Page 10 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. Chatsworth Care - Tudor Lodge DS0000068330.V361306.R01.S.doc Version 5.2 Page 11 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 Chatsworth Care - Tudor Lodge DS0000068330.V361306.R01.S.doc Version 5.2 Page 12 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 to 5 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Prospective residents are being provided with the information they require, in order to make an informed choice as to where to live. The information is being provided in an appropriate format for individuals who have severe communication difficulties. Prospective residents have the opportunity to visit and stay overnight, before deciding whether the home is likely to meet their needs. The home is able to demonstrate that it has the capacity to meet individuals’ assessed needs. Their health, personal and social care needs are set out in an individual person-centred plan of care, and are being reviewed. Each individual has been provided with a service user agreement. These have been prepared in a format that is appropriate to the communication needs of this user group. EVIDENCE: Chatsworth Care - Tudor Lodge DS0000068330.V361306.R01.S.doc Version 5.2 Page 13 The home has sustained and developed its previous good practice in this area and is evidenced to be achieving excellent outcomes for residents. The home’s Statement of Purpose and Service User Handbook are both very comprehensive documents, and meet all the criteria detailed in this standard. The Service User Handbook was last reviewed in January 2008, and provides an appropriate format (using words and symbols) for assisting the understanding of individual service users. The home aims to further develop the Service Users Guide into an ‘easy read’ format containing pictures and symbols. The home uses individualised visual communication systems to assist in enabling effective communication, clarification and understanding. The inspector was advised that the Statement of Purpose is currently being revised. During discussion, the manager advised that the home does not admit individuals with extreme forms of challenging behaviour and that the home had recently to turn down an individual who had been referred, on these grounds. The inspector advised that the home make this exclusion explicit in the Statement of Purpose, stating the reasons for this. A recommendation applies. The home is focussing on meeting the needs of younger adults within the 18 to 30 age range. There are currently five residents at the home, aged from 18 to 25, with one vacancy. These vary from being moderate to severe in their diagnoses. Residents observed by the inspector have presented as being settled and happy in their environment, with staff being attentive to their needs and supportive in their interactions. The home has a very homely and caring atmosphere, this being reflected in the attitudes of management and staff. The homes admissions policy is for the home’s manager or owner to ensure compatibility with other individuals living at the home. Following referral, care management and specialist assessments are obtained. The procedure then involves initial visits from the care manager and parent/nearest relative, followed by a visit from the prospective resident to see the home and meet staff and residents. The manager and deputy manager then arrange to visit the prospective resident, completing their own assessment and requesting psychiatric or psychological reports where necessary. Wherever possible, the home tries to involve the care manager or close relative as an advocate, or seek an independent advocate from within the local area. Once a prospective resident has been assessed, and found to be compatible with others living at the home, he or she is encouraged to visit the home, then stay overnight, followed by another possible overnight stay, and culminating in a weekend stay. This process is designed to enable the prospective resident to Chatsworth Care - Tudor Lodge DS0000068330.V361306.R01.S.doc Version 5.2 Page 14 become familiarised with the home prior to making a decision on whether to move in on a permanent basis. Once the placement has been agreed, a Transition Meeting takes place with the care manager, any relevant professionals, and an advocate if required. A transition plan of action is drawn up, which includes medication, behavoural guidelines and all crucial information which will be required until the person moves in to the home. The transition plan includes a photo of the individual and a personal profile, and details of the key professionals and stakeholders involved in the transition process. Each transition visit is recorded including all positive and negative aspects to ensure that this knowledge is compiled and used to assess the person’s support needs. All information relating to the individual’s assessed needs, personal history, behavioural guidelines, medication/treatment, and risk assessments are incorporated into a person centred care plan upon his/her admission to the home. A communication passport is drawn up prior to when the individual moves into the home. This shows pictures of Tudor Lodge, the prospective resident’s bedroom, the rest of the house, activities they may partake in and areas of their lives that will remain consistent. This includes details of family and friends, staff and other residents that they will be living with, and details of school or college. Favourite belongings are also included to help the person familiarise and become acclimatised to their new environment. The inspector visited the home for a random inspection on 9 November 2007 and met a resident, who had been recently admitted. The admission was evidenced to have been well planned with a transition plan having been drawn up with the individual and his support network. The individual was present during this inspection, and presented as having settled in well. The inspector examined documentation relating to the admission and evidenced that detailed assessments and risk assessments, and a person centred care plan, had been completed. Phone contact with the next of kin confirmed that the placement had gone very well and that the individual has received good support from staff since moving in to the home. Care management assessments and risk assessments, and details of the person’s history have been evidenced on residents’ files, together with assessment reports from psychiatrists and psychologists where these are required. Reviews have been evidenced as being completed within prescribed time-scales. Review notes generally indicate that there has been positive feedback from care managers and relatives regarding the home’s capacity to meet individuals’ assessed needs, and help facilitate their independence and personal development. All residents at the home have been issued with an appropriate and userfriendly service user agreement, this having previously been prepared in draft form at the time of the first inspection. The agreement or contract is agreed Chatsworth Care - Tudor Lodge DS0000068330.V361306.R01.S.doc Version 5.2 Page 15 with the prospective resident and his/her nearest relative, care manager or advocate. This gives details of the terms and conditions of the person’s residency. The individual resident, or his/her representative, signs a copy of the agreement. The contract format uses pictures and symbols, which help to facilitate the individual’s understanding of its contents. Chatsworth Care - Tudor Lodge DS0000068330.V361306.R01.S.doc Version 5.2 Page 16 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 to 10 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are having their health, personal and social care needs set out in an individual plan of care, and are being fully involved in the process of review and care planning. Residents are being assisted to participate fully in the day-to-day life and routines of the home, and are supported by staff in making decisions for themselves in their daily activities. Residents are being consulted regarding their views of issues that individually and collectively affect their lives within the home. Residents are being thoroughly assessed regarding potential risks to their health and safety, and are being enabled to take responsible risks wherever possible. Chatsworth Care - Tudor Lodge DS0000068330.V361306.R01.S.doc Version 5.2 Page 17 EVIDENCE: The home has sustained and developed its previous good practice in this area and is evidenced to be achieving excellent outcomes for residents. The home is involving individuals fully in decisions relating to their care and all aspects of their day-to-day lives. The inspector examined residents’ files. These include detailed and comprehensive service user plans, which follow a person centred plan approach. The person centred care plan has been reviewed and updated within the last year, and is designed to ensure that all staff are well informed and able to use the care plan on a daily basis as an essential working document. The care plans are very detailed and aim to ensure that staff are fully familiarised with all matters relevant to the individuals they are supporting and their particular needs. These provide information evidencing how individuals’ care and support needs are being addressed, the involvement of the individual and their relatives or representatives in drawing these up, and the individual’s right to make decisions in the process. Service user plans provide comprehensive information on how the service will be able to support individuals in meeting their needs, targets, aspirations and goals. They detail all aspects of the person’s life, their personal profile, likes and dislikes, and their communication needs. The plans include care plan objectives, risk assessments, monitoring charts, health action plans, behavioural guidelines, details of the person’s hopes and dreams and review updates.Monitoring forms are completed on a daily basis, and highlight changes in behaviour and general health. All residents have six-monthly and annual reviews. The individual resident and their key worker attends the review meeting, together with close family members, friends and/or representatives, with any relevant professionals also being invited. The care manager is invited for the initial statutory review and subsequent twelve-monthly reviews. Individuals are encouraged to make decisions regarding their day-to-day routines, activities and choices. There is substantial evidence of individuals’ right to make decisions being respected, whether this is in the choice of activities, the use of leisure, choosing clothing or in developing skills and interests. As evidenced in care plans, individuals are being consulted in respect of their day-to-day routines, their choice of food, and their choice of activities. Chatsworth Care - Tudor Lodge DS0000068330.V361306.R01.S.doc Version 5.2 Page 18 There are a number of mechanisms in place for involving residents in the running of the home. Residents attend monthly meetings. These cover a range of issues, such as group activities and outings, and weekly menus, and are facilitated by the manager or deputy manager. Each resident has a key worker who consults on a one to one basis and provides individualised support. Residents also receive regular visits from the home’s owners, Gabrielle and Graham Smith, who actively consult with both individuals and staff. Residents are encouraged to make decisions about anything that may have an impact on their lives, particularly when it involves a transitional situation that involves a change of activity, college or any change in their normal routine. Parents and relatives are involved in the process and are encouraged to visit whenever they can. They are able to attend reviews, doctors, psychologists and psychiatrists appointments if they so wish. The home has a risk assessment procedure which details the risks and level of risk to service users. The inspector examined residents’ files and evidenced the completion of full and detailed risk assessments, together with risk management strategies that have been agreed with individuals. The potential for developing independence is encouraged and enabled wherever possible, subject to safe strategies for managing risks being in place. Risk assessments are reviewed on a six-monthly basis. Chatsworth Care - Tudor Lodge DS0000068330.V361306.R01.S.doc Version 5.2 Page 19 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): Chatsworth Care - Tudor Lodge DS0000068330.V361306.R01.S.doc Version 5.2 Page 20 11 to 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are being encouraged and enabled to develop personal and independent living skills, and have opportunities for accessing appropriate education, training and work experience. Residents are being provided with a wide and varied range of opportunities for participating in recreational and leisure activities, and have extensive contact and links with the local community. The home actively encourages residents to maintain family links and friendships both inside and outside of the home. Residents’ rights and responsibilities are being recognised in their daily lives. Individuals are being enabled to be as independent as possible within the constraints associated with their disabilities. Residents’ privacy is being respected. Residents are being offered a nutritious and healthy diet in a congenial environment. EVIDENCE: The home has sustained and developed its previous good practice in this area and is evidenced to be achieving excellent outcomes for residents. The home is enabling residents to achieve greater independence and fulfilment, to develop their skills and abilities, and to participate as fully as possible within the wider community. Residents are evidenced as being provided with extensive and varied opportunities for personal development, and for developing their social and life skills, learning and capabilities. Service user files evidence that there are detailed individual programmes for residents, with individuals participating in a wide range of educational, social and leisure activities. Two residents attend a local community college (North East Surrey College of Technology) during the week where there is a range of courses offered for people with learning difficulties. One resident attends Orchard Hill Specialist College in Wallington on a full time basis while another attends Sherwood Park School in Wallington. Another resident attends a National Autistic Society day centre on a part time basis. Sutton Mencap provides access to a wide range of community-based Chatsworth Care - Tudor Lodge DS0000068330.V361306.R01.S.doc Version 5.2 Page 21 activities. There is also a local youth club, held on Sundays, which three residents attend. The individual’s preferred method of communication is used in any activity selection process. Daily programmes are arrived at with the individual’s help and reflects their choices and interests. Each programme comprises of a number of varied activities which have been selected for their suitability and compatibility with each resident’s interests and needs. Trials are carried out to assess continuing enjoyment of the activities selected. Activities are individualised, so as to take into account differing needs, abilities, likes and dislikes. As part of the NAS Accreditation Programme, simple goals and targets are set and incorporated into each individual’s person centred care plan. Certificates are awarded for achievement, with new targets being set for continuing development. These achievements include life skills, activities, and community based interests. The home actively encourages residents to access community facilities such as fetes, church fairs, and the local shops. Individuals are assisted to go shopping for food or clothes buying, and to attend community events when these arise. Individuals are able to participate in a variety of recreational and sporting activities. There is a local leisure centre, where individuals participate in a range of activities, which include the gym, trampolining, swimming and dance aerobics. Other community-based activities include horse riding, football, and bike riding. Trips out are arranged. These have included day visits to the London Aquarium, Hampton Court, The National History Museum and open top buses around London as well as visits to various seaside resorts along the South Coast. Residents are encouraged to access public transport, and to use taxis as and when required. The home does not currently have its own minibus. Tudor Lodge also has a flexible list of in-house activities that residents can choose to participate in when they are at home in the evening. These may include cookery, a variety of arts and crafts, sensory activities, computer time, pamper sessions, dvd nights and keep fit sessions. All activities are publicised on residents’ wall charts, each chart using whichever means of communication (pictures, symbols or words) is most appropriate to the individual’s needs. Residents have an annual holiday and are consulted regarding their choice of destination. In September 2007 the holiday destination was Majorca. For some residents this was their first time abroad and the holiday proved to be a real success. Residents are encouraged to maintain contact with family and friends, with opportunities for individuals to visit their family relatives at home for occasional weekends. Relatives and friends are encouraged to visit, with individual residents being able to receive visitors in the relative privacy of the Chatsworth Care - Tudor Lodge DS0000068330.V361306.R01.S.doc Version 5.2 Page 22 conservatory or in their own rooms. There are no set visiting times though visitors are advised to phone prior to arranging to visit. Feedback received by the inspector indicates that family relatives feel that they are being made welcome when they visit the home and that they are being informed and consulted regarding any issues or decisions that affect the individual’s care and well-being. Relatives are routinely invited to attend reviews when these occur. The inspector discussed the possibility of the home extending parental and relative involvement through a relatives’ forum or support group. This was specifically mentioned by one relative, who felt that it would be very beneficial to attend such a group, for mutual support, and for developing relatives’ awareness and involvement with the home. A recommendation applies. The ethos of the home is orientated towards promoting independence and maximising choice and opportunities. Individuals are encouraged to take responsibility for undertaking daily tasks such as cleaning and tidying their rooms, and preparing drinks, food and snacks. Residents’ rights and responsibilities are evidenced from care plans as being respected and recognised in their daily lives, with individuals being enabled to be as independent as possible within the constraints associated with their disabilities. Staff at the home work with the aim of increasing residents’ motivation and confidence, and developing their independent living skills. The inspector has observed that staff engage with residents in a positive and respectful way, and are enabling in their approach. This was again illustrated on this visit, with a key worker being observed to purposefully engage in a short but lively football session with one of the residents, with mutual shared enjoyment of the activity being apparent. Through its involvement in the the Autism Accreditation Programme, the home have devised more effective person centred communication methods for each individual. Training is ongoing with PECS and TEACCH, as well as Makaton, storyboards, visual rotas and menus. Residents’ daily programmes have been devised with their input to reflect their choice and interests. TEACCH style boards are in use for each service user who can see their daily programme each morning, afternoon, day or week ahead, depending on level of ability. Some use pictures, some have makaton signs and others are able to use monthly calenders with written activities on. Goals and targets are set and a star reward and certification system have been put in place to reward achievement. The inspector has observed that the privacy of residents is generally being respected. Privacy is ensured for residents with the help of locks on their bedroom doors and residents have their own keys, if appropriate. Residents also have a locked area in their room for personal items, which provide Chatsworth Care - Tudor Lodge DS0000068330.V361306.R01.S.doc Version 5.2 Page 23 additional privacy and security. Mealtimes are flexible and take account of individuals’ work and activity schedules. Menus evidenced a wide choice of foods, offering a varied and nutritional diet. Professional advice is sought regarding dietary needs when this is required. Residents are consulted individually, and at service user meetings, as to which foods they would like, and are able to assist with shopping at a local supermarket. An alternative dish is provided if the main menu options do not appeal. Staff work alongside residents in preparing food, and with laying table and clearing up. Chatsworth Care - Tudor Lodge DS0000068330.V361306.R01.S.doc Version 5.2 Page 24 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 to 21 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents’ personal support and health care needs are being well met in this home, with support being planned and tailored according to the individual needs presented. Residents are being fully protected by the home’s medication policy, procedures and practice. All staff have now undertaken accredited medication training. EVIDENCE: The home has been developing its previous good practice in this area and is evidenced to be achieving excellent outcomes for residents. The home is appropriately meeting the range of health care, behavioural and support needs Chatsworth Care - Tudor Lodge DS0000068330.V361306.R01.S.doc Version 5.2 Page 25 presented by users, and is providing support that is tailored to individual needs, preferences and choices. The inspector examined residents’ assessments and care plans. These evidence a varied range of communication, behavioural and personal support needs. The support offered is provided according to individuals’ needs, wishes and goals. Inspection of care plans, together with observation and feedback provided from reviews, indicates that staff are enabling in promoting independence and meeting residents’ wishes and needs, and are providing both flexible and focussed support. Individuals are encouraged, wherever possible, to maintain responsibility for their own personal care, hygiene and appearance, with encouragement, prompting or assistance being given where this is required. Where individuals require support with their personal care, this is provided privately in their own rooms. All residents have access to their own en suite bathroom or shower room, and are supported with personal, intimate care by staff of the same gender at a time to suit their personal preference. Guidelines are set out for preferred routines, likes or dislikes as well as guidance and support for personal hygiene where required and specific staff if requested. Feedback received from relatives indicates that staff are perceived to have developed good relationships with residents and to be enabling in their approach. Most comments received were generally favourable, with staff being described as caring and respectful, and welcoming of visitors. While generally pleased with the placement, one relative (next of kin) did, however, feel that communication between staff was not always as good as it could be. This had, on a recent occasion, resulted in a resident not having been reminded to return her call, no phone contact having been received for at least a week. All residents at the home are registered with a local GP practice, where there is a GP with a special interest in learning disabilities. There is access to a community psychiatrist via Sutton’s Community Learning Disabilities Team, with visits being made to the home when required. The home also has access to services such as speech therapy and psychology via the GP, and to community dental and optician services. The home has an ongoing programme of induction and training in place, with staff being provided with training and advice relating to specialist needs such as autism, sensory impairment and challenging behaviour. The home has a clear policy and procedures in place for the receipt, recording, storage, handling, administration and disposal of medicines. A Homely Remedies Policy is also in place to assist staff in alleviating common ailments that may occur but do not require a GP appointment. This has been signed Chatsworth Care - Tudor Lodge DS0000068330.V361306.R01.S.doc Version 5.2 Page 26 and authorised by each resident’s GP. Medicines are stored in a locked medication cabinet on the first floor. This is specific for the purpose of storing drugs and is bolted to the wall inside a second locked area. There is a controlled drugs cabinet within the medication cabinet to store any controlled drugs that may be supplied. These have not been prescribed for any of the existing residents. The consent of residents is sought at all times when administering medication. Guidelines are in place for health professionals to act in the ‘best interests’ of the individual, where it is difficult for an individual to make a decision about their medication. This is in line with the Mental Capacity Act. Each resident has their own medication profile, which outlines any special requirements or personal wishes, regarding the administration of their medication. This also highlights any allergies and includes a photograph of the individual. The home employs the Boots blister pack system. All staff receive a comprehensive induction on the administration of medication. Following their induction, the manager observes the staff member on three separate occasions before being allowed to administer medication. The inspector examined a sample of medication records, which were found to have been appropriately maintained. Two staff (one administering, one observing) are required to sign the MARS sheets following each dispensation of medication. A Boots pharmacist periodically visits the home and gives advice on medication to staff. All but two recently appointed staff have completed accredited medication training, meeting a requirement from the last inspection. Chatsworth Care - Tudor Lodge DS0000068330.V361306.R01.S.doc Version 5.2 Page 27 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 and 23 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home has an appropriate and well-publicised complaints policy and procedure in place. Clear information for raising complaints is made available, and residents and their relatives/friends are encouraged to raise any concerns that they may have. The home’s policies, procedures, training and practice indicate that residents are being fully protected from abuse and are living in a safe environment. All staff attend statutory vulnerable adult training. EVIDENCE: The home has been developing its previous good practice in this area and is evidenced to be achieving excellent outcomes for residents. The home has a clearly formulated complaints procedure that includes the relevant required information, including stages and times-scales, for the complaints process. This is produced in a format, using pictures and symbols, that is appropriate to meeting the communication needs of residents. Residents are provided with the complaints procedure in simplified symbols format which includes help on how to complain to the CSCI at any stage if they so wish. Chatsworth Care - Tudor Lodge DS0000068330.V361306.R01.S.doc Version 5.2 Page 28 Any written complaints are acknowledged within two working days and investigations into written complaints are held within 28 days. All complaints are responded to in writing by either the home’s manager or, if appropriate, by the registered providers. Any complaints or concerns are recorded. Just one complaint has been received since the home opened on 20 November 2006. This has been discussed with the inspector, who is satisfied that the complaint has been appropriately investigated and addressed. The home aims to ensure that residents views are taken into consideration at all times and that these are acted upon wherever possible. Individuals are encouraged to feel confident about approaching anybody in the home with whom they feel comfortable, to express any concerns or anxieties. by the homes staff and manager and Residents are reassured that any concerns, no matter how insignificant, will be taken seriously and that appropriate action will be taken to address these. Clear policies, procedures and guidelines for concerns, complaints and protection of service users are in place for dealing with suspicion or evidence of physical, financial or material, psychological or sexual abuse, neglect, selfharm or degrading behaviour. Staff, residents, family or friends are made aware that they can complain to any person of their choice that they feel comfortable with, or to the CSCI at any stage of their complaint if they wish to do so. The home has its own Protection and Prevention of Abuse policy, and Whistle Blowing policy. All staff are being familiarised with these policies in their induction, and are required to sign to indicate that they have read through these policies and procedures. The home has developed high standards of practice in this area, no allegations of adult abuse having been recorded since the home opened in September 2006.. Staff at the home are required to develop their skills and awareness in this area and to attend relevant training courses. These are organised by an inhouse qualified training officer, Chris East. The training programme includes induction and training in adult abuse. There is regular POVA (Protection of Vulnerable Adults) training every six months with updates for all staff, together with regular training sessions on adult abuse. All staff are required to be fully aware of local statutory adult protection procedures, and to complete statutory vulnerable adult training. The manager has confirmed that it is the home’s policy to ensure that any new staff are enrolled on this training at the earliest opportunity. Chatsworth Care - Tudor Lodge DS0000068330.V361306.R01.S.doc Version 5.2 Page 29 Chatsworth Care - Tudor Lodge DS0000068330.V361306.R01.S.doc Version 5.2 Page 30 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): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents live in an environment, which is safe, well maintained and adapted for people with disabilities. Users have access to sufficient and comfortable communal facilities. Residents’ rooms are safe, comfortable and pleasantly decorated, reflecting service users’ personal identities, and being suited to their individual needs. Residents’ toilets and bathrooms provide sufficient privacy and meet individual needs. The home presents as being clean and hygienic, and as a pleasant and homely environment in which to live. EVIDENCE: Chatsworth Care - Tudor Lodge DS0000068330.V361306.R01.S.doc Version 5.2 Page 31 The home has been maintaining and developing its high standards in this area and is evidenced to be achieving excellent outcomes for residents. Tudor Lodge has been open since November 2006, all building and environmental work having been completed to a very high standard. The home is situated in a quiet and very pleasant residential road within a much sought after area of Sutton. The home is a large detached property, with six bedrooms spread between three floors. The home provides a very congenial and safe environment and has been refurbished to cater for the needs of the residents. The home is kept as non-institutional as possible, and provides an environment in which the residents are able to exercise control and maintain their individuality and independence. The inspector carried out an inspection of the premises. The home presents as very well maintained and has been decorated to a high standard. The home is pleasantly furnished, with modern-style furniture in all areas. There are two communal lounges, both of which are well laid out. These provide a pleasant and homely place to relax and spend time. The other, larger lounge is comfortably furnished and opens out into a very attractive conservatory where residents can relax or entertain visitors. There is a large and well-equipped open-plan kitchen with a well laid-out dining area, giving it a very homely feel. Visual rota’s and visual menus/choices are displayed in the kitchen/dining area. Each resident has their own bedroom, which has sufficient useable floor space to meet individual needs and lifestyles. All bedrooms are in excess of 12 square meters, and include either an en suite bathroom/toilet, or a shower room/toilet. There is a bathroom on the first floor, and a toilet on the ground floor, which are for the use of staff and visitors. Five of the six bedrooms are currently occupied. These are personalised to reflect individuals’ tastes and identities, with all residents having choice of colour and personal items. All residents have a locked cupboard in their rooms. All furniture, including a comfortable chair, bedding, TV and electrical equipment are supplied by the proprietors unless a service user wishes to supply their own. The home presents as safe and well adapted to the needs of the current residents, all of who are relatively young and able to mobilise freely around the home. The home has a risk assessment in place, and each individual is risk assessed on admission. The home presents as being clean and pleasant, with high standards of hygiene being maintained throughout. Areas inspected included the kitchen, laundry room, communal areas and bedrooms. No concerns were identified. Staff are required to attend food hygiene and infection control training, and Chatsworth Care - Tudor Lodge DS0000068330.V361306.R01.S.doc Version 5.2 Page 32 there are policies and procedures in place that relate to the maintenance of hygiene in the home. The home has a very large, attractive garden at the rear which residents are encouraged to use and enjoy. Some activities are available in the garden. These include heavy-duty swings, a basketball hoop and football net. The garden is tended by a gardener, and residents are encouraged, if they so wish, to be involved with this activity. There is a vegetable patch at the rear of the garden where one resident’s efforts have proved successful in growing onions and a variety of other vegetables. Chatsworth Care - Tudor Lodge DS0000068330.V361306.R01.S.doc Version 5.2 Page 33 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): 31 to 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff have clearly defined roles and responsibilities, and are sufficient in numbers to meet service users’ needs. Residents are having their needs well met by an appropriately trained and qualified staff group. Residents are being protected by appropriate recruitment policy and procedures. Generally, residents are benefiting from staff who are being well-supported. However, staff are not presently receiving sufficiently regular supervision. EVIDENCE: An application package is sent out to prospective staff members. This includes a comprehensive application form and a Person Specification. This highlights the essential and desirable requirements for a support worker, particularly in relation to autism and complex disabilities. When applications are received an interview is arranged at the home and is undertaken by two staff from the Chatsworth Care - Tudor Lodge DS0000068330.V361306.R01.S.doc Version 5.2 Page 34 management team. The home has an appropriate recruitment policy and procedure in place. This is based on equal opportunities principles and aims to ensure the protection of residents. There have been a number of new staff appointments since the last inspection. The inspector examined the relevant staff files and evidenced that all CRB, POVA, identity and recruitment checks had been satisfactorily completed. Staff benefit from clarity of staff roles and responsibilities, with detailed job descriptions being in place. Each staff member attends an initial induction programme at the home, which is spread over 3 months. This includes the principles of care, the organisation and role of the worker, maintaining safety at work, communication skills, recognising and responding to abuse, and developing as a worker. Workbooks accompany each section of the induction process to ensure that training and knowledge has been assimilated. All new staff are allocated mentors throughout the induction process. This programme is followed by a six-week period of observation and further training, with the new staff member working alongside an experienced staff member. A three-month probationary period applies. After a three months probationary period, the new member of staff meets with the home’s manager and the training manager to discuss their proposed development and individual training plan. The plan details the relevant training needs, learning objectives, timescale and evaluation outcomes, and is monitored and updated by the training manager. As part of the plan, all staff are given the opportunity to undertake HSC level 2. At this stage, the new member of staff commences an Autism Focus Workbook, and is subsequently mentored and supported through to completion. The training manager then plans interactive training sessions, which include Understanding Autism, the Challenges of Autism and Meeting the Challenges of Autism. The training manager confirmed that these training sessions are held periodically throughout the year. Chatsworth Care has its own training manager, Chris East, who has responsibility for the training of staff within Tudor Lodge and its two companion homes, Dawson House (in Sutton) and Greenacres (in Banstead). She works closely with the homes’ managers in identifying and meeting training needs, and has developed a comprehensive on-going in-house training programme. The programme for 2007 was evidenced, and discussed with the training manager. This ensures that all staff receive both the necessary range of mandatory training, and the specialised training required, for working with individuals who have learning disabilities, autism, and challenging behaviour. Training also covers first aid, fire safety, health and safety, food hygiene, infection control, moving and handling, medication, abuse awareness and Chatsworth Care - Tudor Lodge DS0000068330.V361306.R01.S.doc Version 5.2 Page 35 POVA (Protection of Vulnerable Adults), equality and diversity, and antidiscriminatory practice. Chatsworth Care also purchases external training in a number of specialised areas. This includes communication methods, crisis intervention strategies and prevention, social interaction and makaton. The inspector viewed the staff rota, and was satisfied that the staffing complement for the home meets appropriate DOH guidelines. There are currently 5 staff at all times, when all residents are present, enabling staff to provide the 1:1 support required. There are two waking staff on-call at night. The 1:1 ratio assists residents to access their various daily programmes, and provides the necessary level of support for the management of complex and challenging behaviours and sensory problems relating to autism spectrum disorders. All staff sign and date a record to indicate that they have read and understood each policy and procedure that has been put in place and reviewed. Staff Meetings are held monthly and provide a forum for discussing issues that relate to practice and the running of the home. All staff receive supervision, with supervision records being maintained. These are signed by the supervisee following each supervision session. Supervision is shared between the manager and deputy manager, with probationary reviews being completed with all new staff after their first 3 months. Supervision includes structured discussion regarding issues that relate to staff members’ practice, training and development. The inspector examined a sample of staff files and was concerned to find that there were long gaps (3 months or longer) between supervision sessions. Of 10 staff files examined, none met the standard (36.4) of ‘at least six times a year’. In three cases there was no record of any supervision having taken place within the last six months. The manager has indicated that several sets of supervision notes had been completed but had not been returned to the home. However, these records were not able to be evidenced at the time of inspection. All records of supervision should be available at all times. The manager was reminded that supervision is a high priority, and must be held with all staff on a regular basis. A requirement applies. Support of staff is however, generally good, with excellent training, monitoring and annual appraisal of staff taking place. There is an appraisal process in place, which includes a self-evaluation form to be completed by each staff member. Sampling of staff files indicated that up-to-date appraisals have been completed for all support staff. Chatsworth Care - Tudor Lodge DS0000068330.V361306.R01.S.doc Version 5.2 Page 36 Chatsworth Care - Tudor Lodge DS0000068330.V361306.R01.S.doc Version 5.2 Page 37 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 to 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is being run competently, and in the best interests of the home’s residents. The home has developed its quality assurance processes, and is obtaining the views of residents, relatives and professionals. Residents’ rights and best interests are being safeguarded by the home’s record keeping, and by its policies and procedures. The health, safety and welfare of residents and staff are being appropriately promoted and protected. EVIDENCE: Chatsworth Care - Tudor Lodge DS0000068330.V361306.R01.S.doc Version 5.2 Page 38 The registered manager, Kerrie Roach, completed her NVQ Level 4 and the RMA (Registered Managers Award) in August 2005. She is qualified as a Learning Disability Nurse and has had previous management experience of running a residential home, both as a deputy manager and as an acting manager. The deputy manager is also qualified to NVQ Level 4, and has obtained an NVQ Assessors Award. The management approach within this home is of a generally high standard, with ample evidence that the home is promoting excellent practice and achieving positive outcomes for residents in their day-to-day lives. Feedback obtained from questionnaires, phone sampling and review minutes indicates that the home is held in high regard and that the interests of residents are being generally well served. The home’s providers and management have demonstrated that they are fully committed to raising standards further through the development of best practice, the commitment to training, and the progression towards having obtained NAS (National Autistic Society) accreditation and Investors in People. The manager, Kerrie Roach, presents as having a good knowledge and understanding of the needs of this client group, and has been able to demonstrate her competency regarding issues relating to the day-to-day running and management of the home. From his observations, and discussion with staff members and others, the impression gained by the inspector is of a happy, well-run home, with staff feeling generally well supported and valued. The one area in which there has been a decline in standards from the last inspection is that of staff supervision. While management support of staff is generally taken very seriously, there has, nonetheless been a significant lapse in this area which needs to be rectified. The home has been developing quality assurance processes and has completed surveys with residents, relatives, staff, GPs and relevant professionals. The questionnaire for residents is presented in an appropriate format for service users, and includes the use of Makaton and verbal prompts. The AQAA states that feedback is given to all those who take part in the survey, and that actions are taken in response to any suggestions that are raised. Chatsworth Care - Tudor Lodge DS0000068330.V361306.R01.S.doc Version 5.2 Page 39 A quality assurance audit report was completed in February 2008. The manager advised that a monthly Quality Action Group has just recently been set up, comprising of representatives from all three Chatsworth Care homes. And that the main purpose of the group is to share ideas and good practice, and to develop new ways and methods of working. From the evidence of this inspection, residents and staff records are generally being well maintained. Records and documentation examined by the inspector were found to be comprehensive, up to date and accurate. Residents are able to gain access to their records and any information held about them. In line with data protection, all records are being kept securely in lockable filing cabinets within an office on the top floor. The home has a comprehensive range of policies and procedures in place. Some were not recorded as having been reviewed, though the home has since confirmed that these had, in fact, been reviewed and updated. It does, however, need to be evidenced at the time of inspection that all policies and procedures have been annually reviewed. The inspector conducted an inspection of the premises and completed health and safety checks. Generally, the home presents as a safe and pleasant environment in which to live. The home has completed health and safety and fire risk assessments. The fire risk assessment is due for review from 18/4/08. Up-to-date health and safety certificates are in place for electrical installation, portable electrical appliances, fire alarm installation, emergency lighting and gas safety. The manager advised that all staff at the home are undertaking fire safety training on a six monthly basis, and that there are monthly fire drills. Other health and safety checks such as water temperature (weekly) and fridge/freezer checks (daily), and fire alarms tests (weekly), are being completed on a regular basis. Chatsworth Care - Tudor Lodge DS0000068330.V361306.R01.S.doc Version 5.2 Page 40 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 4 3 4 4 4 5 4 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 4 ENVIRONMENT Standard No Score 24 4 25 4 26 4 27 4 28 4 29 X 30 4 STAFFING Standard No Score 31 4 32 4 33 4 34 4 35 4 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 4 4 4 LIFESTYLES Standard No Score 11 4 12 4 13 4 14 4 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 4 X 4 3 4 4 3 4 X Chatsworth Care - Tudor Lodge DS0000068330.V361306.R01.S.doc Version 5.2 Page 41 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 YA36 Regulation 18 (2) Requirement All staff must receive supervision at least six times a year. Timescale for action 03/04/08 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 YA1 Good Practice Recommendations The home needs to make explicit in the Statement of Purpose that it does not admit individuals with extreme forms of challenging behaviour, and state the reasons for this. The inspector recommends that the home give consideration to a forum or support group for the relatives and friends of residents. 2 YA15 Chatsworth Care - Tudor Lodge DS0000068330.V361306.R01.S.doc Version 5.2 Page 42 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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 Chatsworth Care - Tudor Lodge DS0000068330.V361306.R01.S.doc Version 5.2 Page 43 - 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. 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