Inspection on 27/02/06 for Abbey Lodge

This inspection was carried out on 27th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Abbey Lodge 09/08/07

Abbey Lodge 08/05/06

Abbey Lodge 31/08/05

Similar services:

Chesham House

Argyll House

Dorset Lodge

Acacia House

Falcon House

Dial House Nursing Home

Cromwell Avenue (9)

Conquest House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Abbey Lodge 55 Harvey Road London Colney Herts AL2 1NA Lead Inspector Patricia Rogan Unannounced Inspection 27th February 2006 10:00 Abbey Lodge DS0000062483.V285590.R01.S.doc Version 5.1 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 Abbey Lodge DS0000062483.V285590.R01.S.doc Version 5.1 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. Abbey Lodge DS0000062483.V285590.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Abbey Lodge Address 55 Harvey Road London Colney Herts AL2 1NA 01727 825899 01727 825899 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) Mrs Meetranee Chintaram Mr Krishna Iyapah Care Home 4 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (4), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (4) Abbey Lodge DS0000062483.V285590.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st August 2005 Brief Description of the Service: Abbey Lodge is located in a semi-detached house in a residential area of London Colney, with access to both local shops and services and by public transport to St Albans city centre. The home offers a service for four adults of any age who have a mental disorder. Accommodation is on two floors - there is one bedroom with en-suite shower on the ground floor and three bedrooms on the first floor, one with an en-suite toilet and wash basin. Staff sleeping-in accommodation is also on the first floor. There is a lounge/dining area, kitchen and office on the ground floor. The laundry is in an outhouse linked to the kitchen by a covered walkway, where service users may smoke if they wish. The garden is laid to lawn and flowerbeds. Abbey Lodge DS0000062483.V285590.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second inspection of the inspection year and took place during the morning. The registered manager was present and for part of the inspection, a member of staff was also present. The inspection included a brief tour of the premises, inspecting some records and discussing any changes since the previous inspection. Where key standards were assessed at the previous inspection of 31st August 2005, these have not all been assessed again. Reference should be made to the report of that inspection for details. What the service does well: What has improved since the last inspection? What they could do better: The staff sleep-in room is largely used for the storage of a third party’s clothing and personal toiletries, giving the appearance of a private bedroom and is therefore unsuitable as staff sleep-in accommodation. The manager has been advised that he must familiarise himself with the correct procedure when notifying CSCI of events in the home. Abbey Lodge DS0000062483.V285590.R01.S.doc Version 5.1 Page 6 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. Abbey Lodge DS0000062483.V285590.R01.S.doc Version 5.1 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 Abbey Lodge DS0000062483.V285590.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 4 Discussion with the manager and records seen showed good practice when assessing prospective residents. EVIDENCE: Prospective residents are involved in discussion about what the manager is able to offer to meet the resident’ needs. The manager said he welcomes the opportunity to show a prospective resident around the home and have a trial stay to ensure a placement would be suitable. Abbey Lodge DS0000062483.V285590.R01.S.doc Version 5.1 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 10 The Statement of Purpose and discussion with the manager about confidentiality shows that this is regarded as important. EVIDENCE: The records are appropriately stored and not accessible to other residents. The residents are made aware that they can speak to staff members in confidence, with the assurance that if there are any concerns, the manager will try to find a resolution to any difficulty. Abbey Lodge DS0000062483.V285590.R01.S.doc Version 5.1 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 16 Residents are encouraged to attend outside educational and social activities. The residents are involved in making choices about how they want to live their lives on a daily and long-term basis. EVIDENCE: The care plans are individualised and reflect the resident’s aspirations. When the resident has expressed an interest in an activity, the manager will try to make this possible if it is practical and safe to do so. One example of this is that when a resident decided to take a long distance holiday, arrangements were put in place for this to happen and a member of the Team has accompanied this resident. Abbey Lodge DS0000062483.V285590.R01.S.doc Version 5.1 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 and 21 The manager has improved the medication administration since the previous inspection although the dispensing procedure requires adjustment. The manager is sensitive to the health care needs of residents and in addition to records being kept, residents have many opportunities to speak in confidence and privacy. EVIDENCE: The manager has put into place procedures for recording medication and for the return of medication. One resident’s medication had been dispensed into an unnamed dosette box and stored on the resident’s named shelf in the locked medication cupboard. This does not meet the guidelines. The manager addressed this on the day of inspection but it would be helpful if he was to have further training or guidance on how medication should be dispensed. The advantage of this small home is that the permanent staff know the residents very well and have a knowledge and understanding of resident’s needs. In the event of illness, residents are reassured and appropriate health care and support is made available. Abbey Lodge DS0000062483.V285590.R01.S.doc Version 5.1 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Residents are given opportunities to speak with staff on an individual basis and in group meetings and they are supported if they wish to speak to people outside the home. The ‘Hertfordshire Adult Protection Procedure’ handbook is readily available in the home. The manager said staff also work in other establishments and have had training in this procedure in those work places. EVIDENCE: The residents chat as a group with the staff during meal times and at any time of the day, residents can speak to staff in privacy. Residents can also make private telephone calls to speak to friends and family or professionals involved in their care. There are also structured group and individual meetings when residents can express their views. There have been no complaints on record until recently. This complaint is being investigated appropriately. The manager has been made aware that he should have informed CSCI of the details of the incident and any decisions made according to Regulation 37. Abbey Lodge DS0000062483.V285590.R01.S.doc Version 5.1 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 25, 26, 27 and 28 The residents’ rooms are personalised according their own taste and their privacy is respected. Shared spaces for service users are homely and appropriately furnished and equipped. The staff sleep-in bedroom has the appearance of a private bedroom, having a full rail of personal clothing and toiletries. EVIDENCE: Each bedroom is decorated and furnished to reflect the resident’s choice and lifestyle. Residents are enabled to maintain their privacy and each resident is made aware that respect for each other is paramount. There is a knock and wait policy for staff. The shared spaces are maintained to a high standard whilst retaining a homely, comfortable appearance, with the exception of the staff sleep-in accommodation which appears to be used as a private bedroom. Abbey Lodge DS0000062483.V285590.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 34 and 35. Service users are supported by a small, established staff group and therefore, clarity of roles and responsibilities are more evident. Occasionally, Agency staff are used but the manager said he tries to keep to the same Agency staff so that residents know them. Staff had mandatory training when they started working in Abbey Lodge. EVIDENCE: Abbey Lodge is a small home and therefore staff and residents share meals and leisure times which provides every opportunity for service users to be clear about the roles and responsibilities of the staff who support them. The staff have had CRB clearance and references were followed up prior to recruitment. The manager said in addition to mandatory training, staff work in other health care settings and have training in many fields including adult protection procedures. Abbey Lodge DS0000062483.V285590.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38 and 42. The home appears to be well run and previous feed back from the residents was favourable. The manager is keen to provide a pleasant and supportive environment for the service users. There are procedures in place to promote the welfare and protection of service users but the registered person should ensure familiarity with the procedures. EVIDENCE: The premises have a homely appearance and is well maintained. The manager liaises with outside agencies in order to support the residents. He is keen to promote the service users’ opportunities to benefit from their experience in residential care. To this end, he has tried to address the requirements from the previous inspection. There was a delay in giving notice and information to CSCI orally and in writing about an alleged incident which evidences that the manager is unfamiliar with the correct procedure. Abbey Lodge DS0000062483.V285590.R01.S.doc Version 5.1 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 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 2 23 2 ENVIRONMENT Standard No Score 24 X 25 3 26 3 27 3 28 2 29 X 30 X STAFFING Standard No Score 31 3 32 X 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 X 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 3 3 3 X X X 2 X Abbey Lodge DS0000062483.V285590.R01.S.doc Version 5.1 Page 17 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 Standard YA20 Regulation 13(2) Requirement Timescale for action 30/04/06 2 YA23 13(6) 3 YA42 37(1) & 37(2) 4 YA28 23(3)(b) The registered manager must seek information and advice from a pharmacist regarding the correct method of dispensing medication for individuals in the home. Robust procedures for 30/04/06 responding to suspicion or allegations of abuse must include passing on concerns to the Commission for Social Care Inspection. The registered person must give 30/04/06 notice to the Commission without delay of the occurrence of any event which comes under Regulation 37. Any notification made in accordance with this regulation should be given orally and confirmed in writing. Sleeping accommodation for 30/04/06 staff must be suitable for all sleep-in staff and not used as a private bedroom. Abbey Lodge DS0000062483.V285590.R01.S.doc Version 5.1 Page 18 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Abbey Lodge DS0000062483.V285590.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ National Enquiry Line: 0845 015 0120 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. 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