Care Home: Herons Lodge

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What the care home does well People`s care plans tell staff how they like their needs met. People receive good support to stay healthy. People eat good food which they help to cook. People have regular meetings, to make decisions about what happens at Herons Lodge Staff help people to stay in contact with their families. Staff receive training to make sure that they know how to meet people`s needs. What has improved since the last inspection? Improvements have been made to the bathrooms in the home so they are more comfortable and safe for people to use. There are more staff on duty so that people living in the home can do more things. The manager has time to manage the home properly. Staff have received extra training to help them support people better. Confidential records are now locked away when they are not being looked at. What the care home could do better: Staff need some extra training on how to make sure people are kept safe. Key inspection report Care homes for adults (18-65 years) Name: Address: Herons Lodge 138 Northampton Road Market Harborough Leicestershire LE16 9HF The quality rating for this care home is: one star adequate service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Ruth Wood Date: 2 0 0 4 2 0 1 0 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should:  Be safe  Have the right outcomes, including clinical outcomes  Be a good experience for the people that use it  Help prevent illness, and promote healthy, independent living  Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home:  3 stars – excellent  2 stars – good  1 star – adequate  0 star – poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area Outcome area (for example: Choice of home) These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement Care Homes for Adults (18-65 years) Page 2 of 32 Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by:  Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice  Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983  Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services.  Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 32 Information about the care home Name of care home: Address: Herons Lodge 138 Northampton Road Market Harborough Leicestershire LE16 9HF 01858465441 01858465441 ninaroberts@mentaur.ltd.uk www.mentauruk.com Mentaur Community Support Limited Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Type of registration: Number of places registered: Conditions of registration: Category(ies) : care home 10 Number of places (if applicable): Under 65 Over 65 10 10 0 0 learning disability mental disorder, excluding learning disability or dementia Additional conditions: The maximum number of service users who can be accommodated is 10. The registered persons may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission are within the following category: Learning disability - Code LD Mental disorder - Code MD. Date of last inspection 1 1 0 8 2 0 0 9 Care Homes for Adults (18-65 years) Page 4 of 32 A bit about the care home Herons Lodge is a care home for people with learning disabilities or mental health problems. Ten people can live at the home. It is close to the town centre of Market Harborough. There are shops, pubs, restaurants and a post office in Market Harborough. There are two lounge areas and a dining room on the ground floor. Each person in the home has their own bedroom. There are bedrooms on the first and second floors. You can get to the bedrooms using the stairs. One bedroom has its own toilet and shower. There are four other communal bath and shower rooms for people to use. The home has a garden. People pay different amounts to live a Herons Lodge depending on how much support they need. The manager will be able to tell you how much you will have to pay. People pay extra for hairdressing, clothes, toiletries and holidays. The service users guide tells people about what it is like to live at Herons Lodge. Care Homes for Adults (18-65 years) Page 5 of 32 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home Care Homes for Adults (18-65 years) Page 6 of 32 How we did our inspection: This is what the inspector did when they were at the care home Before we visited Herons Lodge we looked at the information sent to us about what has happened there since we last visited on 28 May 2009. This included information from the manager about how Herons Lodge tries to meet the needs of people living there. We sent surveys to people who live in the home and to staff who work in the home. 4 people living in the home sent their surveys back. 4 staff sent their surveys back. We visited Herons Lodge on Tuesday 20 April 2010. We arrived at 09:30 in the morning and left at 5 oclock in the afternoon. We looked at all the rooms in the house. We spoke to people who live at Herons Lodge. We watched how staff spoke and worked with people who live at Herons Lodge. We looked at 2 peoples care plans. We spoke to staff about how they support people. We spoke to staff about the training they did. We looked at staff records. These told us about the checks done to make sure staff Care Homes for Adults (18-65 years) Page 7 of 32 have the right skills and are safe to work in the home. We spoke to the manager about how the home is run. What the care home does well Peoples care plans tell staff how they like their needs met. People receive good support to stay healthy. People eat good food which they help to cook. People have regular meetings, to make decisions about what happens at Herons Lodge Staff help people to stay in contact with their families. Staff receive training to make sure that they know how to meet peoples needs. Care Homes for Adults (18-65 years) Page 8 of 32 What has got better from the last inspection What the care home could do better Staff need some extra training on how to make sure people are kept safe. Care Homes for Adults (18-65 years) Page 9 of 32 If you want to read the full report of our inspection please ask the person in charge of the care home If you want to speak to the inspector please contact Ruth Wood CPC1 Capital Park Fulbourn Cambridge Cambridgeshire CB21 5XE 01223771300 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line - 0870 240 7535. Care Homes for Adults (18-65 years) Page 10 of 32 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 11 of 32 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Information about the home is clearly written and up to date. This helps people to make an informed decision about coming to live at Herons Lodge. Assessment procedures are in place to make sure that the service can meet peoples needs. Evidence: The Statement of Purpose and Service Users Guide were last updated in March 2010 and the information they contain accurately reflects the service provided at Herons Lodge. Each person living at Herons Lodge has a copy of the Service Users Guide. This contains pictures to help people to understand the information better. At the time of the inspection visit the home had 4 vacancies. We discussed with the Acting Manager how she and her team assessed people before they came to live at Herons Lodge and what opportunities people had to come and visit the home to see what it was like to live there. The manager told us about a person who has visited the home with their family. The manager has also visited the person to find out about their needs and whether the staff at Herons Lodge can meet them. Arrangements are being made to Care Homes for Adults (18-65 years) Page 12 of 32 Evidence: speak in more depth to the persons carers and their care manager to put together a care plan before the person moves into the house on a trial basis. Care Homes for Adults (18-65 years) Page 13 of 32 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples needs are outlined in well-written care plans and they are supported to take reasonable risks and to make choices. Evidence: We looked at two peoples care plans and spoke to two staff members about how they supported these people. We also spoke to and observed the two people in the home and how staff interacted with them. Each persons care plan gives good information about how they should be supported and includes detail about their personal preferences for morning and evening routines, social activities, personal care and communication. The plan also outlines how people make choices about what they would like to eat, whether to have a shower or a bath and what activities to be involved in. One person told us that they would like to go to the shops on the morning of the inspection and was supported to do this by a staff member. The staff that we spoke to demonstrated a very good understanding of peoples needs, which corresponded with the information contained in each persons care plan. Care Homes for Adults (18-65 years) Page 14 of 32 Evidence: People are also supported to make choices by their keyworkers who meet with them on a weekly basis. One person has decided that they would like to go on holiday to Norfolk this year and their keyworker is helping them to arrange this. During our visit the person and their keyworker were planning the kinds of activities they would like to do while on holiday. People are also encouraged to make choices about what they eat and what they do, at the weekly service users meetings. A senior staff member showed us how pictures, cookery books and prompt cards are used to help people decide on the menu for the week. Care plans also contain clearly-written risk assessments, which assist staff in managing identified risks. Because of particular needs, some people have some restrictions placed upon some aspects of their behaviour, for example in relation to food and drink. Where these restrictions are in place there is clear, documented evidence that external agencies such as the team dealing with the Deprivation of Liberty Standards has been consulted, that these restrictions have been assessed by this team and found to be proportionate to the persons needs and to be the least restrictive option. Care Homes for Adults (18-65 years) Page 15 of 32 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported to engage in a varied lifestyle. People enjoy a well-balanced diet in pleasant surroundings. Evidence: Each person living at Herons Lodge either attends a specialist day service Monday to Friday or has alternative arrangements in place. For one person this involves one to one time with a staff member going for walks and to the shops or spending time at the home working on their computer. Most people were getting ready to go to their day placements when our inspection visit started and appeared happy and relaxed to attend and appeared equally happy and relaxed when they returned. A group of four people and two staff went out in the homes transport to feed the ducks at a local beauty spot to take advantage of the good weather. Another person helped the staff member to prepare tea in the kitchen. Each person has the opportunity to help prepare meals in the kitchen and there is a rota Care Homes for Adults (18-65 years) Page 16 of 32 Evidence: to say which day they will do this. People choose what they want to eat for their main meals at the weekly service users meeting but choose breakfast and light meals on the day. Each persons food intake is recorded individually and these records show that people receive a well-balanced, varied diet although one person commented on their survey that they wanted, more ice cream and cakes.. Peoples cultural choices about food are also respected. Two people have decided to go away on holiday this year and their key workers are helping them to plan and arrange this. Other people will go on day trips. Several people living in the home go to a disco held in Leicester every week and once per month a musician visits the home, bringing instruments for people living in the home to play. People also enjoy going out to the local pub and into Market Harborough to the visit the shops and cafes. Staff support people to stay in contact with their families by helping them to buy and send celebration cards and by supporting them to visit their families; for some people this is a weekly event. One person is supported to eat a diet appropriate to their particular religion and has also been supported to celebrate that religions festivals. We discussed with the acting manager how this person may be further supported to understand their culture and she agreed to explore this with the persons family and social worker. Care Homes for Adults (18-65 years) Page 17 of 32 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples health and personal care needs are well met Evidence: The two care plans that we looked at outlined peoples personal care needs in detail and identified whether people enjoyed a bath or a shower and personal preferences in relation to their clothes and hair. We observed that there had been a significant improvement in several peoples personal appearance and demeanor since the last key inspection. Three people have had their hair restyled to take account of their individual needs, including those relating to their culture. People appeared much more alert; for example two people who did not acknowledge the inspectors presence at the previous visit were now curious and willing to communicate. Each persons daily routine is also outlined in an easy read format in their bedrooms. We noted on our tour of the home that one person was allocated two hours for personal care each morning. The manager said that this person did not like to rush and that sometimes they didnt need this long but that staff were available if they did. Each person has a Health Action Plan and these are to be updated using a new format following recent training undertaken by the acting manager and some of the senior staff. The plans give information about each persons health care needs as well as how they Care Homes for Adults (18-65 years) Page 18 of 32 Evidence: may communicate if they do not feel well or are in pain. A record is kept of all healthcare appointments and the two people whose care that we looked at in detail had undergone a recent healthcare check at their local GP surgery. We looked at the arrangements for the storage, administration and recording of medication. All of these were in good order. Those staff authorised to give medication have received appropriate training and two staff routinely administer medication, one observing the process and signing to say that it has been administered correctly. Very clear guidance is in place in relation to medication taken by people on an as required basis; this can include medication to calm peoples challenging behaviour as well as medication for pain. Such medication cannot be administered without the authorisation of a senior staff member. An examination of the Medication Administration Records demonstrated that there had been no use of as required medication during that administration period. Care Homes for Adults (18-65 years) Page 19 of 32 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Some improvements in training and practice are required to make sure that people are consistently protected Evidence: Each person living in the home has a personalised, easy-read copy of the complaints procedure in their bedroom. This gives information about what to do if they are not happy with anything at Herons Lodge and the various people they can contact. Peoples care plans contain information about how people express anger or distress; this is important as some people living in the home find it difficult to communicate using formal language. Staff spoken with were aware of how the people whose care that we looked at in detail expressed their distress or displeasure. We looked at the complaints and concerns record and noted that complaints received are recorded. Not all information relating to an investigation, the outcome of the investigation and the action taken by the organisation is available in this record. This information should be available for inspection. We discussed a recent safeguarding incident in the home with the acting manger. The manager said that the concern had been raised with her by a staff member and that she had recorded this and conducted an investigation. Following discussion the manager agreed that under safeguarding protocols to protect vulnerable people, she should have referred the concern to social services for them to determine the most appropriate person and/or agency to investigate. We strongly recommend that all staff, including the acting Care Homes for Adults (18-65 years) Page 20 of 32 Evidence: manager and senior staff refresh their training in safeguarding. To ensure that they are following correct local multi-agency protocols we recommend that this training be accessed from the appropriate local authority. Prior to this report being issued the acting manager contacted us to confirm that this training had been arranged for herself and all staff working in the home. Discussion with staff and staff training records confirmed that staff have received training in None Aggressive Physical and Psychological Intervention (NAPPI) to help them to respond appropriately to behaviour from people living in the home which may be challenging. Staff have also received training in understanding the Mental Capacity Act and the Deprivation of Liberty Standards. Where restrictions have had to be placed on people in their best interests, the Deprivation of Liberty Standards team has been contacted to assess whether these restrictions are reasonable and to make recommendations. (Please see also Individual Needs and Choices outcome group) Care Homes for Adults (18-65 years) Page 21 of 32 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a clean and comfortable home which meets their needs Evidence: Before the inspection visit we received a complaint that the mattress of a person who used to live at the home was stained and needed replacing. Because of this information we looked at all the bedrooms in the home (including those currently unoccupied) and inspected the mattress and the bedding to ensure that they were all of a reasonable standard. We found that the mattress the person had spoken about was stained but all the other mattresses in the home were of a reasonable standard. The acting manager said that systems had now been put in place to ensure that this would not happen again. As part of their duties keyworkers had to check peoples rooms on a weekly basis and inform the manager of any repairs or replacements that were needed. We suggested that it would be good practice to use a notebook for staff to record this information and for the manager to record when the problem had been rectified. The stained mattress (which was no longer in use) was replaced by a new one before the end of the inspection visit). We noted that each persons room was individually decorated. All areas of the home were clean and fresh and there were no unpleasant smells anywhere in the home. We spoke to staff and saw documentary evidence that confirmed they had received training in infection control. Care Homes for Adults (18-65 years) Page 22 of 32 Evidence: At the previous key inspection we made requirements and recommendations for improvements to various aspects of the environment. All bath and shower rooms now have appropriate window coverings which allow people to bathe in privacy. All bath and shower rooms have adequate heating in place, which has been made safe by the use of radiator covers. The shower room on the top floor has been re-furbished and is now able to be used. Polystyrene tiles (identified by services consultant fire inspector as a potential fire risk) have been removed from the office ceiling and the ceiling has been replastered. Care Homes for Adults (18-65 years) Page 23 of 32 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported by competent, well-trained staff Evidence: There are currently six people living at Herons Lodge. Examination of the rota and the way that people are supported, indicates that staffing levels are appropriate to meet peoples needs and allow for them to make choices about their lifestyle and activities. People who responded to our Have Your Say survey expressed satisfaction with the way that staff supported them, although one person said, I want more women on shift. We observed that people living in the home interacted well with both male and female staff members. The majority of staff employed by the home are female. The four staff Have Your Say surveys we received said that recruitment checks were completed by the company before they started work in the home. We checked three staff recruitment records during the inspection visit and these contained all the required information, including, Criminal Records Bureau checks, two written references and evidence of the persons identity. There was evidence in one persons interview record that a person living in the home had been involved in their interview. The four staff who responded to our Have Your Say survey said that they received training relevant to their role, which helped them to meet peoples needs. The two staff that we spoke to said that they had received statutory training in such areas as first aid Care Homes for Adults (18-65 years) Page 24 of 32 Evidence: and fire safety, training in mental health conditions and autism and in understanding the implications of the Mental Capacity Act. Copies of staffs certificates were also in place together with a training matrix showing which staff have completed which training and when. Staff also have the opportunity to undertake National Vocational Qualifications; one staff member that we spoke to is currently completing their level 3 award, the other staff member had completed this. The acting manager said that when staff had completed their NVQ awards she wished them to start their Learning Disability Qualification; she had already obtained the workbooks for this award. We saw records of regular one to one supervision sessions between staff members and the acting manager or one of the senior supervisors. Staff who responded to our survey confirmed that they received regular support from their managers. Care Homes for Adults (18-65 years) Page 25 of 32 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Herons Lodge is currently a well managed service Evidence: The current acting manager has been in post since August 2009 and has made significant improvements to the way the home is managed. All requirements made at the previous key inspection have been met and the manager and provider have also worked with external agencies to action recommendations arising from safeguarding referrals. The way that staff are deployed in the home has also been modified to afford the manager sufficient time to attend to their administrative and supervisory duties. The current acting manager is due to leave Mentaurs employ at the end of the year and in anticipation of this a replacement manager was recruited in February to work alongside the existing manager and to take over responsibility for the home when they leave. This person has now applied for registration under the Care Standards Act. A variety of systems are in place to ensure the ongoing quality of the service provided in the home. The provider makes visits to the home and writes a report and feeds back any areas of concern to the manager. A formal quality assurance process takes place in which Care Homes for Adults (18-65 years) Page 26 of 32 Evidence: people living in the home and their relatives are asked for their views of the home and the staff who support them. An audit of the way peoples finances are managed also takes place as part of this process. A formal report outlining the outcomes of this process is produced and this includes recommendations for future practice. Regular staff meetings take place and service users meetings take place on a weekly basis. Both these meetings are documented and demonstrate that efforts are made to include service users in the way the home is run. Improvements have been made in the way that information is documented and stored in the home with all confidential documents now stored in an appropriate way. External consultants are employed to ensure that the service meets essential standards associated with health and safety and fire safety. Staff records demonstrate that staff have received training in statutory areas such as health and safety and food hygiene, first aid and fire safety. Fire records show that alarms and equipment are regularly tested and serviced. Care Homes for Adults (18-65 years) Page 27 of 32 Are there any outstanding requirements from the last inspection? Yes  No  Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No Standard Regulation Requirement Timescale for action 1 1 5 The registered person must 30/09/2009 forward a copy of the revised service user guide to the Commission This is to ensure that the guide is an accurate reflection of the service provided. 2 20 13 The services medication 20/08/2009 administration policy should be reviewed and a copy of the updated policy should be forwarded to the Commission. This should include details of the grade and experience of staff who are authorised to administer medication and the arrangements in place to ensure their ongoing competency in this area. This is to ensure that people living in the home are protected 3 24 23 The registered person must 31/08/2009 ensure that the shower room on the second floor is made fit for use. This is to ensure that people with a room on this floor Care Homes for Adults (18-65 years) Page 28 of 32 Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No Standard Regulation Requirement Timescale for action have easy to toilet and washing facilities on the same floor. 4 24 23 The registered person must ensure that all the homes bath and shower rooms are equipped with safe heating. 31/08/2009 This is to ensure that people living in the home can bathe or shower without getting cold and without the risk of burning themselves on uncovered radiators or heated towel rails. 5 35 18 The registered person must 30/09/2009 ensure that all staff have received appropriate training in working with people with learning disabilities and mental disorder This is to ensure that all staff have the training and skills necessary to meet the needs of the people for which the home is registered. Care Homes for Adults (18-65 years) Page PAGE of NUMPAGES Requirements and recommendations from this inspection Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No Standard Regulation Description Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set No Standard Regulation Description Timescale for action 1 23 13 31/07/2010 The registered person will ensure that all staff members working at Herons Lodge receive re-training in safeguarding vulnerable adults. This is to ensure that all managers and staff working at Herons Lodge are aware of the multi-agency protocols in place to safeguard vulnerable adults and the action they as individuals should take to make sure that people are protected. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 22 All information relating to how a complaint was investigated, the outcome and the action taken by the Page 30 of 32 Care Homes for Adults (18-65 years) Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations provider should be including in the official complaints record. 2 23 We strongly recommend that all managers and staff working at Herons Lodge attend safeguarding training provided by the Local Authority to ensure that they are fully conversant with the current multi-agency safeguarding protocols. Care Homes for Adults (18-65 years) Page 31 of 32 Helpline: Telephone: 03000 616161 or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. Care Homes for Adults (18-65 years) Page 32 of 32 - 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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