Inspection on 15/12/05 for Alice Lodge

This inspection was carried out on 15th December 2005.

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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Alice Lodge 02/05/08

Alice Lodge 22/11/07

Alice Lodge 02/05/06

Alice Lodge 31/01/05

Alice Lodge 06/12/04

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 Alice Lodge 40 Brighton Road Purley Surrey CR8 2LG Lead Inspector Michael Williams Unannounced Inspection 15th December 2005 11:00 Alice Lodge DS0000025748.V273544.R01.S.doc Version 5.0 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 Alice Lodge DS0000025748.V273544.R01.S.doc Version 5.0 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. Alice Lodge DS0000025748.V273544.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Alice Lodge Address 40 Brighton Road Purley Surrey CR8 2LG 020 8668 8448 020 8763 0706 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) Ms Alice Manteaw-Dankyi Care Home 16 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (16) of places Alice Lodge DS0000025748.V273544.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th July 2005 Brief Description of the Service: Alice Lodge is one of a number of care homes owned by this proprietor Mrs Dankyi trading as ‘Alice Care Homes’. This particular home has recently been refurbished throughout. The home caters for adults with mental illness. There are 14 bedrooms, some ensuite two shared and some are now ensuite. There is a large open-plan lounge and a separate dining room. The home the usual facilities for such a home including kitchen, small laundry, office bathrooms and toilets. The home has a smoking room and garden to the rear and parking to the front. Alice Lodge DS0000025748.V273544.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a brief unannounced inspection conducted at midday and with the assistance of many of the service users. Most the key standards were inspected and found to have been met during the previous inspection in July so this inspection was used to confirm any key standards not assessed or not fully met previously. What the service does well: What has improved since the last inspection? 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. Alice Lodge DS0000025748.V273544.R01.S.doc Version 5.0 Page 6 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 Alice Lodge DS0000025748.V273544.R01.S.doc Version 5.0 Page 7 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): 2 Service users are being assessed prior to admission so as to assure those prospective service users that all their health and social care needs, including their mental health needs, could be met if they are admitted to the home. EVIDENCE: Key standard in this section was not re-evaluated on this occasion other than to confirm pre-assessment assessments continue to be undertaken and are held on the service users’ case file. New service users confirm that they are given the opportunity to visit the home and to regard their first weeks as a trial period and say they look forward to staying in the home and receiving support and help in their rehabilitation. Alice Lodge DS0000025748.V273544.R01.S.doc Version 5.0 Page 8 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): Service users know that their changing needs are reflected in their care plans and they will share in decision making about their care and about responsible risk-taking. EVIDENCE: The key standards in this section were not re-evaluated on this occasion but were found to have been met in the manner indicated above. Alice Lodge DS0000025748.V273544.R01.S.doc Version 5.0 Page 9 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): Only key standard 16 was re-assessed on this occasion the others were met. The service users arrange their own activities and contact with the community and develop such relationships as their mental health allow. Their rights to freedom of movement has been re-instated. EVIDENCE: Only standard 16, about service users’ rights, was not fully met because their freedom of movement was restricted by unsuitable locks on the front door. This matter has now been corrected so service users are not confined to the home without lawful authority. Alice Lodge DS0000025748.V273544.R01.S.doc Version 5.0 Page 10 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): Service users are supported by care staff and the service users confirmed that they can ask for help and get support in a manner that suites them. Service users’ physical and mental health needs are being met to ensure their welling. A range of support mechanisms are in place to support service users in taking their medication - this enables service users to either manage their own medicines in a safe manner or receive support from staff. EVIDENCE: These key standards were assessed as met in July in the manner outlined above. Alice Lodge DS0000025748.V273544.R01.S.doc Version 5.0 Page 11 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 23 Arrangements are in place for service users and their representatives to either complain or compliment the service and suitable procedures are in place to deal with any complaints that may arise. This ensures that service users’ views are taken into account. Policies, procedures and staff training are in place; this is to protect the vulnerable service users. EVIDENCE: No complaints arose during the course of the inspection; the home has recorded two since the previous inspection and these were recorded as` having been dealt with in an appropriate manner by the manager. Staff are aware of their responsibility to protect service from abuse and to report untoward incidents to the correct authorities. Service users were very complimentary about the home, the premises and the staff team. Alice Lodge DS0000025748.V273544.R01.S.doc Version 5.0 Page 12 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): 24 30 Alice Lodge has been refurbished throughout and so it is a safe and homely environment for service users. It is also kept in a clean and tidy condition for the benefit of service users. EVIDENCE: The new manager accompanied the inspector on a tour of the premises and indicated those areas requiring improved ventilation have now been attended to including for example, a shower room, the kitchen and a bedroom. Other areas remain clean, tidy and odour free. Only very minor work remains outstanding from the refurbishment work such as making good the door fame to the fire exit adjacent to the front door. The kitchen and laundry are now in full working order and service users were making use of these facilities during the inspection – demonstrating the home’s facilities provide opportunities for the residents to practice their daily living skills. Alice Lodge DS0000025748.V273544.R01.S.doc Version 5.0 Page 13 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): 32 34 The staff team hold a variety of qualifications and so ensure service users are supported by competent staff; recruitments practices have improved so the well being and interests of service users are protected. EVIDENCE: During the previous inspection it was noted that some staff were being employed in the home without the necessary recruitment checks being in place. This has been corrected and all staff have undergone the necessary checks including police (CRB) checks, references, health and identity checks and so forth. Staff hold a range of relevant qualifications including mental health nursing qualifications and several hold the advised N.V.Q. (National Vocational Qualification) at levels 2 to 4. Three staff are booked to undergo N.V.Q. training. Whilst not all staff at this time have NVQ at 2 or greater they do a have range of relevant qualifications and experience. Staff were interviewed to confirm they receive ongoing training support and supervision and that they are aware of their responsibilities to support and protect services users. Alice Lodge DS0000025748.V273544.R01.S.doc Version 5.0 Page 14 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 39 41 42 This is a well run home; the new manager has not yet applied for registration and so the CSCI has yet to assess his qualifications, skills and experience to be registered and manage the home but he was well organised on the day of inspection and this clearly to the benefit of service users who can be assured that their views about the home underpin the running of the home. EVIDENCE: The acting manager says he has previously managed supported-living accommodation for people with mental health problems. The CSCI registration process will be used to formally evaluate whether or not he is to be registered but on the day he appeared to be running the home very competently for the benefit of service users. The matter of unsuitable door locks identified in the previous inspection have now been addressed ensuring service users have free access into and out of the building. A sample of records were checked, including kitchen, accident, money, complaints records, and in general are satisfactory but the food record needs refinement; the director’s visits are to be recorded and the incident record needs to be located as it was not available on the day. Hot radiators need to be protected if they pose a hazard to residents. Accounts, three monthly as minimum, must be provided in the home when residents’ money is held by the company and not in the home itself. Alice Lodge DS0000025748.V273544.R01.S.doc Version 5.0 Page 15 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Alice Lodge Score X X X x Standard No 37 38 39 40 41 42 43 Score 2 X 3 X 2 2 X DS0000025748.V273544.R01.S.doc Version 5.0 Page 16 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA37 Regulation 8(1) Requirement Manager: The provider must make application to register a manager for this home without unreasonable delay. Records: All the statutory records listed in the Schdeules 1 to 4 must be mainainted up to date, accurate and available for inspection by CSCI – including Director’s monthly visits (Regulation 26) and the incident record (Regulation 37). Records: When service user’s personal money is held by the head office the service user must be provided with a regular (no less than three monthly) account of that money and copy must be made available for inspection by the CSCI. Health & Safety: The home must be coducted so as to protect service users from hazards; fire fighting equipment must be checked at least annually. Health & Safety: Hot water and hot surfaces such as radiators must be no greater than 42o C or covered. Timescale for action 30/04/06 2 YA41 17 30/01/06 3 YA41 17 28/02/06 4 YA42 13(4)(a) 30/01/06 5 YA42 13(4)(a) 28/02/06 Alice Lodge DS0000025748.V273544.R01.S.doc Version 5.0 Page 17 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA3 Good Practice Recommendations Diversity and Equality: whilst the home has staff from a range of backgrounds it is suggested that guidance is provided on specific cultural expectations so that the home can make suitable arrangements to ensure the home is run with due regard to the sex, religious persuasion, racial origin, and cultural and linguistic background and any disability of service users. Staff qualifications: Whilst recognising that staff have a variety of formal qualifications relevant to their role, it remains a recommendation that the home ensure that suitably qualified staff are available having regard to the size of the home and the number of service users; the NMS indicate 50 of staff with suitable NVQ qualifications are needed. 2 YA32 Alice Lodge DS0000025748.V273544.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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. Extracts may not be used or reproduced without the express permission of CSCI Alice Lodge DS0000025748.V273544.R01.S.doc Version 5.0 Page 19 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!