Care Home: Concord Lodge

Similar services:

• 2 Perhaver Park
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What the care home does well Concord Lodge has developed its services into an assessment unit with one place for a person whose needs are very complex and requires one to one care. Individuals can be confident that the home will strive to provide a personalised package of care. In meeting the needs of the individuals it is evident that the staff work closely with other professionals complimenting the skills of the team at Concord Lodge. Individuals are encouraged to be active in the planning of their care and to be as independent as their abilities allow. What has improved since the last inspection? Concord Lodge is a service that has changed over the years and it was evident that this process is still ongoing. The service is being developed as a treatment and assessment unit for individuals with a learning disability providing short term care with the emphasis on moving people back into the community. What the care home could do better: Individuals and their representatives would benefit from the statement of purpose being amended making it clearer the length of time that individuals can stay at Concord Lodge and why the length of stay has been agreed in respect of the medium and the respite stay. The home must make an application to vary the certificate of registration in relation to the person who has stayed longer than the six months agreed period. Individuals must be assured that care documentation is current and accessible. Where individual`s liberty is being deprived this must be clearly documented in the plan of care assuring an open and transparent service is being provided. A current photograph of each service user must be kept in the home. CARE HOME ADULTS 18-65 Concord Lodge Kellaway Avenue Horfield Bristol BS7 8SU Lead Inspector Paula Cordell Unannounced Inspection 28th January 2008 10:30 Concord Lodge DS0000037289.V355250.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 Concord Lodge DS0000037289.V355250.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. Concord Lodge DS0000037289.V355250.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Concord Lodge Address Kellaway Avenue Horfield Bristol BS7 8SU 0117 3532385/86/87 0117 353 2387 concord_lodge@bristol-city.gov.uk 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) Bristol City Council Mr Glyn Short Care Home 6 Category(ies) of Learning disability (7) registration, with number of places Concord Lodge DS0000037289.V355250.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. May accommodate 7 persons aged under 65 years. A separate dedicated staff team must be available for a person when accommodated in the Safe Haven facility Residents will stay no longer than six months in the home unless agreed by CSCI 27th February 2007 Date of last inspection Brief Description of the Service: Concord Lodge is registered to provide personal care and accommodation for up to six persons (male and female) who are under 65 years of age and who have a learning difficulty. Concord Lodge provides medium term care for a period of six months. During this time individuals will be assessed and more suitable permanent placements will be sought. The service supports individuals with complex care needs and who at times can challenge services. A safe haven Service has been established to support individuals who cannot be easily accommodated with others and would benefit from interim specialist support to reduce challenging behaviour. The staff at Concord Lodge work in partnership with the Bristol Intensive Response Team to provide this service. In addition the home has one respite bed, which is in the process of being developed to provide a short break to people with complex needs and who sometimes challenge. The staff work in partnership with the Bristol Adult Placement Team and the Day Services Community Resource Team. At time of writing this report the fees were levied at £64 per week. There are additional costs where individuals choose to the use services of a Hairdresser £5.00-£20.00, Chiropody £17.00 and Reflexology £25.00 a session. Concord Lodge DS0000037289.V355250.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This was an unannounced visit as part of a key inspection process. The purpose of the visit was to review the progress to the requirements from the visit in February 2007 and monitor the quality of the care provided to the individuals receiving a service at Concord Lodge. Prior to the visit some time was spent examining documentation accumulated since the previous inspection, including correspondence and notified incidences in the home (Regulation 37’s). Feedback from relatives and individuals receiving care was sought through comment cards. Two comment cards were received from professionals and families and friends and two from individuals that receive a service at Concord Lodge. During the site visit, the records were examined, a tour of the premises conducted and feedback sought from individuals and the staff on duty. There have been no concerns received about the service prior to this visit and the visit in February 2007. The visit was conducted over six hours. What the service does well: What has improved since the last inspection? Concord Lodge DS0000037289.V355250.R01.S.doc Version 5.2 Page 6 Concord Lodge is a service that has changed over the years and it was evident that this process is still ongoing. The service is being developed as a treatment and assessment unit for individuals with a learning disability providing short term care with the emphasis on moving people back into the community. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Concord Lodge DS0000037289.V355250.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 Concord Lodge DS0000037289.V355250.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 adequate. This judgement has been made using available evidence including a visit to this service. Sufficient information is available about the services provided at Concord Lodge however it was not clear how this was shared with the individual or their representatives. Individuals care needs are being assessed prior to a placement being agreed. The home is in breach of a condition of registration with individuals exceeding the timescale of six months. EVIDENCE: The home has a statement of purpose that describes the services available. This could be made slightly clearer in relation to the timescales for example the medium term assessment six months and the respite bed for a period of no longer than six weeks as in parts the document is contradictory and could be misunderstood. The service user’s guide includes photographs and has been written in plain English this makes sure that people wishing to use the service find it easier to understand the content. Concord Lodge DS0000037289.V355250.R01.S.doc Version 5.2 Page 9 Completed surveys from relatives and people receiving a service were mixed in whether they had been consulted on whether to move to Concord Lodge. Both relatives said they had not been consulted and neither had received information prior to moving to the home. Individuals and their relatives must have information available to them in the form of the statement of purpose and the service user guide. There is a condition of registration that states that the home should not provide a service for a period longer than six months. From speaking with staff and reviewing care documentation it was evident that two individuals have exceeded this time limit with one person living in the home for a period over twelve months. From talking with staff, this has been out of their control however the provider, Bristol City Council have employed a social worker to look for suitable placements for the individuals and to assist with meeting this timescale. The Social Worker is based at Concord Lodge three days per week with the sole purpose to find suitable accommodation for the individuals when they have been assessed as ready to move on. From reading the care documentation it was evident that placements have been found but for various reasons they have not been suitable for the individual. The Social Worker stated that they have been in post since January 2008. The home must ensure that they keep the Commission for Social Care Inspection informed of individuals that have exceeded the six-month period by submitting an application to vary the conditions of registration. Three case files were studied and all had assessment information that had been completed prior to the individual being accepted into the home. There was evidence that people and their families have the opportunity to visit the home prior to moving in and this is part of the assessment process. The home has protocols for an emergency admission. There were assessments made by the placing Social Worker but the deputy manager said that they always make sure they do their own assessment as well. From reading one person’s assessment information it was not clear why they had been admitted to the home. It was not clear what level of challenge the person exhibited and how this individual met the criteria to move to the home. Staff stated that the reason the person had moved was that the individual had exceed the time limit at another Bristol City Council respite care service. During the last visit it was noted that there were contracts recording the services offered by the home and the cost. As well as any additional costs. These were written in plain English and included pictures and symbols so that they were easier to understand. This was not reviewed on this occasion. Concord Lodge DS0000037289.V355250.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): 6,7,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals can be confident that their needs are being met. Care is tailored to the individual. Care files are not accessible and would benefit from a formal review to ensure information is current. Whilst this is not having an impact on the individuals it would better demonstrate the work that is being undertaken to support the people living at Concord Lodge. Individuals are actively involved in the planning of their care. Individuals are encouraged to take risks within a risk assessment framework. Concord Lodge DS0000037289.V355250.R01.S.doc Version 5.2 Page 11 EVIDENCE: Four care plans were looked at as a means of determining the processes the home goes through to support the individuals living at Concord Lodge. Care plans detailed the support needs of the individuals focusing on life skills and personal care and how staff should support individuals with behaviours that may challenge. The care plans were of a variable standard. There was no clear index to the file and some care plans seen were no longer relevant as they made reference to previous placements. It was difficult to navigate the files. Each person had a current day-to-day file containing care plans and daily recording records, a second file containing correspondence, health care appointments, monthly key worker reviews and assessments and care plans. Then a third file compiled by the placing social worker with further correspondence and assessments and care plans. It was not clear how the monthly key worker review updated the home’s care plan although it contained lots of valuable information. One of the care plans seen was written in 2006 but there was no evidence that this has been formally reviewed and updated. One of the deputy managers at the end of the visit provided evidence that this was being addressed. A new format for recording care plans was being introduced, which detailed the need and a space for recording a review. This process had commenced for two of the individuals and was going to cascade to all staff at the next staff meeting. From talking with the deputy manager it was evident that the frequency of the review would vary depending on the level of the need. This is good practice. During the visit the inspector heard about several people who had made very good progress in developing skills in activities of daily living whilst living at Concord Lodge and were either in the transitional phase of moving on or had moved. It was evident that staff were knowledgeable about the needs of the individuals and how they liked to be supported. It was evident from talking with staff that the service was person centred and tailored to the individual. Individuals had assigned key workers to support them to ensure consistency. The individual living in the safe haven annex has a dedicated team of staff to support them, but this was true for the other individuals. The deputy stated that individuals have four or five key staff allocated to them to ensure that each shift is covered with a member of staff that knows the individual. Staff confirmed that this happened in practice. From talking with staff it was evident that each person is allocated a member of staff to support them during the shift and the shift is led much by the individual on what they want to do. Concord Lodge DS0000037289.V355250.R01.S.doc Version 5.2 Page 12 The deputy manager stated that staffing is determined by the individual’s assessment of care, where individuals need additional staffing this is accommodated. Where individuals are preparing to move on, staffing may be withdrawn if this is appropriate especially where this person may be moving to a more independent setting. Again it was evident that the care was tailored to the individual. People were allowed to take risks and these were seen in the assessments that were in place. These had been regularly reviewed and kept up to date to reflect the changing needs of the person. Families of people using the service said that the quality of care is good and that they were aware that the home was used for assessment. One relative was pleased that the individual had made good progress whilst living at Concord Lodge. It was clear they were kept informed of important changes to the care of the individual and involved in the decisions that were being made. The deputy manager stated that the individuals are consulted on a daily basis on what they want to do and to ensure that they are happy with the care being delivered. The individuals on admission and discharge complete questionnaires. These were not viewed on this occasion. Concord Lodge DS0000037289.V355250.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals are supported to lead the lifestyles that they choose. Individuals benefit from an individualised service being provided. A healthy diet is provided to the individuals living in the home. Concord Lodge DS0000037289.V355250.R01.S.doc Version 5.2 Page 14 EVIDENCE: People that use the service have the opportunity to be involved in activities with people of their own age group. A number attend various day centres and others are employed in the local area. From talking with staff it was evident that individuals would participate in the activities that they pursued prior to admission where possible. All the people have the opportunity to go out either on a one to one with staff or in small groups. Activities in the community include going to pubs and restaurant, shopping, cinema and bowling. There are also activities available in the home and include games and puzzles, music and reflexology. On the day of the visit people were supported to go to the shops, for a walk and to day centres. One individual was keen to share and show their arts and crafts that they have made. It was evident that this was accommodated in the home an area had been designated for the person to complete this safely. Individual activities are recorded and staff work hard to make sure that people continue with their interests and pastimes. Where a risk had been seen these are assessed to make them as safe as possible while not over protecting the person making the activity meaningless. It was evident that these were updated in response to changing needs and updated as part of the continual assessment process. Though there are meal times these are flexible because many of the people are out at some part of the day. Some of the individuals are encouraged to prepare their own meals as part of the assessment process for the move to supported living other individuals have their food prepared by the cook or the staff. Menus seen were varied and healthy. Special diets are catered for including cultural choices. Concord Lodge DS0000037289.V355250.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals can be assured that their personal and health care needs are being met. Individuals are protected by the home’s robust medication systems. Concord Lodge DS0000037289.V355250.R01.S.doc Version 5.2 Page 16 EVIDENCE: Care plans evidenced that individual’s personal and health care needs were being met. Evidence was provided that individuals have access to health professionals including access to a GP, dentist, opticians and chiropody. The deputy stated that where possible people can retain their GP prior to admission or if this is not possible the individual temporarily registers with the local surgery. Individuals have access to primary health care including the community learning disability team. It was evident that the home works closely with other professionals as part of the ongoing assessment process. Other professionals included psychiatry, occupational therapists, speech and language therapists, community learning disability nurses and psychology. Individuals were being supported in a respectful and sensitive manner. It was evident that the individuals in the home could choose when to get up and go to bed. This was evidenced via care documentation, observation and through conversations with staff. Medication systems were robust, including recording, policies and procedures and storage. Two staff are involved in the administration of medication, with the second person acting as a witness. Staff have attended training on safe administration of medication and their competence is assessed. Concord Lodge DS0000037289.V355250.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. Individuals can be confident that good systems are in place to address concerns and ensure individuals are protected from harm. Concord Lodge DS0000037289.V355250.R01.S.doc Version 5.2 Page 18 EVIDENCE: The home’s Complaints procedure is written in a simple format with pictures to ensure that the people for whom its intended can understand it. Completed surveys confirmed that individuals were aware of the complaint procedure. One person stated that they relative could not verbally communicate their concerns but the individual could express whether they were happy or not. Completed surveys from relatives felt staff were responsive to the needs of the person living in the home. The home maintains a complaints record, which lists the name of the complainant, the nature of the complaint and the actions to be taking to address the concern. There have been no complaints in the last twelve months. The Bristol City Council’s “No Secrets” policy is available at the home and staff have attended Safeguarding Adults training. Staff were aware of the reporting procedures where abuse is suspected. The home has a whistle blowing policy. The home supports individuals that at times can challenge. Clear guidelines were in place to support the individual and offer staff direction. All staff have training in supporting individuals that challenge and this is updated every six months. Records were seen confirming this. Two of the staff have attended training to enable them to fulfil the role of cascading this to the staff team. In addition the home has close links with a specialist behaviour team. A deputy manager stated that restraint is not used in the home. Concord Lodge DS0000037289.V355250.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24-30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Concord Lodge provides individuals with a safe place to live that is clean, however this will be improved when the new building is built and in use. No requirements have been made relating to the environment in light of the new premises. Concord Lodge DS0000037289.V355250.R01.S.doc Version 5.2 Page 20 EVIDENCE: Concord Lodge is situated in a residential area close to local amenities including a sports centre, places of worship, shops, pubs and restaurants. Concord Lodge consists of a large house and out buildings. Some of the outbuildings are not owned by Bristol City Council and have fallen into a poor state of repair. Others are being used as office spaces for the administrator, manager and the social worker. Bristol City Council have successfully submitted plans to build a new unit on the same grounds as Concord Lodge. The plans were available in the office. The new build will consist of one unit split into seven self-contained flats. Each flat will have a bedroom, lounge, bathroom and kitchen. It is evident that this would be more suited to the needs of the individuals that the home intends to support. Concerns were raised about the layout of the building taking into consideration that some of the individuals can have some challenging behaviour. The home is a warren of corridors. However, the staff have creatively provided individuals with their own personal space including a sitting room, bedroom and their own bathroom facility. Some of the areas have a kitchen. Staff stated that the environment is changed to suit the individual. It was noted that one room looked like a communal lounge/dining room but it contained a bed. Whilst it is not the norm for a care home to change the space around for example a lounge would not normally double up as a bedroom, in this scenario it is evident that the accommodation was viewed more flexibly to support the people. From talking with staff it was evident that for some individuals the environment could play a part in escalating behaviours that challenge. The deputy stated that as part of the assessment process prior to individuals moving to the home the environment is discussed to ensure the area is suitable. Areas seen were personalised by the individuals staying in the home. Whilst some areas were looking tired no requirements have been made in light that the new building is on target for opening in late summer. No application has been received in respect of the registering of the new build. Concord Lodge DS0000037289.V355250.R01.S.doc Version 5.2 Page 21 The home uses a keypad system to divide areas off. This includes the kitchen, the office and external doors. This was documented in a generic risk assessment. It was not clear how it linked to the individual’s plan of care. As this is seen as with-holding an individual’s liberty it must link to the individual’s plan of care and risk assessment. The keypad system must be kept under review. The staff team have an established office in the centre of the building and the manager’s office is in the annex in the grounds of Concord Lodge. The home was clean and free from odour. Domestic staff are employed to assist the care staff with cleaning chores. The home has a large industrial kitchen. This was clean and well organised. From reviewing records it was evident that good food hygiene principles were being adopted. Concord Lodge DS0000037289.V355250.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient and competent staff support the individuals at Concord Lodge. Effective communication systems were in place within the home with staff feeling supported however, this would be enhanced if formal supervisions were regularly organised. Concord Lodge DS0000037289.V355250.R01.S.doc Version 5.2 Page 23 EVIDENCE: The staffing rota and conversations with staff provided sufficient evidence that the home is staffed to meet the needs of the individuals in line with the home’s statement of purpose. There was a minimum of five staff working in the home throughout the day with two staff providing night cover. There was a dedicated team of staff supporting the Safe Haven facility during the day. Recruitment information was not seen as Bristol City Council has an agreement where all information relating to staff recruitment is held at a central office. This will be subject to a separate inspection. Evidence was provided that all staff that have worked in the home in excess of three years have recently completed a new criminal record bureau check. This is good practice and demonstrated a commitment to ensure that individuals are further protected. Staff complete a comprehensive induction including the Learning Disability Qualification. This was confirmed in staff files seen. Ongoing training relating to the needs of the people living in the home was in place including statutory health and safety training. A member of staff stated that they have been given the role to co-ordinate the training in the home. It is evident that all training information is being audited with a new matrix being introduced. A member of staff stated that autism training is planned for the beginning of February 2008. There are clear lines of accountability in the home, which includes a registered manager, four deputies, care officers and care assistants. Staff were aware of the roles in the home. Staff were allocated areas of responsibility. Evidence was provided that regular staff meetings take place to discuss both the running of the home and issues relating to the care of the individuals. Monthly key worker meetings are organised where key staff meet up to discuss progress of the individuals. Less apparent was formal supervisions for staff. One staff appeared not to have any since August 2007, three staff have not had one since October 2007 and one member of staff has not received formal supervision since 2002. A member of staff stated that senior management are always available for support. Concord Lodge DS0000037289.V355250.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual’s benefit from a well-managed service. Good health and safety systems are in place ensuring the safety of the individuals during they stay at Concord Lodge. Concord Lodge DS0000037289.V355250.R01.S.doc Version 5.2 Page 25 EVIDENCE: Mr Glyn Short is the registered manager. Staff spoke positively about the manager’s “open” style in management and the support he gives to the team at Concord Lodge. In addition to the registered manager, the home has deputy managers, care officers and care assistants. Quality assurance initiatives are taking place looking at various aspects of the running of the home. One member of staff stated they were responsible for auditing the training and devising a plan to ensure that all staff attend appropriate training to their role. The individuals staying at Concord Lodge on admission and discharge complete questionnaires on their stay. This was discussed with staff during the visit, as some of the individuals have stayed longer than six months and whether questionnaires should be given more frequently. It was also noted that relative’s views are not sought as part of this process. Good health and safety systems were in place. There is a named health and safety representative within the team. Risk assessments were in place for fire, COSSH, manual handling and food safety. These had been kept under review and ensured safe working practices were in place. Staff clearly described the support mechanisms that are in place when supporting individuals that challenge. All staff have access to a portable emergency call bell which will alert other staff in the building to assist where necessary. Staff stated that where they have been involved in an incident of aggression staff support is given both during the incident and a debriefing session is arranged shortly after with the senior management team. In addition staff receive regular training to enable them to support individuals with challenging behaviour. From observations during the visit it was clear that staff communicated clearly where they were in the building and who they were supporting. Concord Lodge DS0000037289.V355250.R01.S.doc Version 5.2 Page 26 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 2 2 3 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 x 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Concord Lodge DS0000037289.V355250.R01.S.doc Version 5.2 Page 27 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard YA1 YA1 Regulation 4 (1) Sch 1 Care Standards Act Requirement For the statement of purpose to be made clear in respect of the length of stay for individuals. For the home to make an application to vary the certificate of registration in relation to the person who has stayed longer than the six months agreed period. To keep the care plans under review ensuring information is current. Where the keypad is depriving an individual of their liberty this must be recorded in the plan of care how this is impacting on the individual and the reasons why. This must be kept under review. A current photograph of each service user must be kept in the home. Timescale for action 29/03/08 29/02/08 3. 4. YA6 YA24 15 (2) 17 (1) (a) Sch 3.3 (q) 29/04/08 29/02/08 5. YA6 17 (1) (a) Sch 3.2 29/02/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Concord Lodge DS0000037289.V355250.R01.S.doc Version 5.2 Page 28 No. 1. 2. 3. Refer to Standard YA6 YA36 YA39 Good Practice Recommendations For care files to be clearly indexed. Where information is no longer relevant for this to be archived. All staff to receive at least six supervisions per annum. For relatives views to be sought in respect of the service where relevant. Concord Lodge DS0000037289.V355250.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Concord Lodge DS0000037289.V355250.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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