Inspection on 02/05/08 for Alice Lodge

This inspection was carried out on 2nd May 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 14 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Alice Lodge 22/11/07

Alice Lodge 02/05/06

Alice Lodge 15/12/05

Alice Lodge 31/01/05

Alice Lodge 06/12/04

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Cherry Tree House

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOME ADULTS 18-65 Alice Lodge 40 Brighton Road Purley Surrey CR8 2LG Lead Inspector Michael Williams Key Unannounced Inspection 1st May 2008 10:00 Alice Lodge DS0000025748.V361682.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 Alice Lodge DS0000025748.V361682.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. Alice Lodge DS0000025748.V361682.R01.S.doc Version 5.2 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 Registration pending Care Home 16 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (16) of places Alice Lodge DS0000025748.V361682.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (CRH - PC) to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Mental Disorder, excluding learning disability or dementia - Code MD The maximum number of service users who can be accommodated is: 16 22nd November 2007 Date of last inspection Brief Description of the Service: Alice Lodge is one of a number of care homes owned by this proprietor Mrs Dankyi. This particular home has been refurbished throughout. The home caters for adults with mental illness. There are 14 bedrooms, some are shared and some are ensuite. There is a large open-plan lounge, a separate dining room and small smoking room. The home has the usual facilities for such a care home including kitchen, small laundry, a very small office, plus bathrooms and toilets. The home has a small conservatory and garden to the rear and limited parking to the front. Fees as at April 2008 were from £525 to £690. Alice Lodge DS0000025748.V361682.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 1 star,. This means the people who use this service experience adequate quality outcomes. As part of the key inspection a site visit was made to Alice Lodge on 2nd May 2008. Residents on the premises were given the opportunity to meet with the inspector. Staff were interviewed including ancillary staff. The Owner, Mrs Dankyi and the General Manager were present for part of the inspection. The owner has appointed another manager who is in the process of being registered by the Commission but was not registered at the time of this inspection visit. We also checked a number of records. Questionnaires were distributed to the residents, staff and visitors. We also took note of any information provided to the Commission. What the service does well: What has improved since the last inspection? What they could do better: Primary concern was the limited number of staff on duty when we visited. We noted that a number of incidents and matters of concern had occurred recently, most noticeably the damaged to the fabric of the building arising from residents’ conduct. This pointed to inadequate supervision of residents and so a revision of staffing levels is required. Other safety issues include errors in recording medicines and resident’s money. Alice Lodge DS0000025748.V361682.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Alice Lodge DS0000025748.V361682.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 Alice Lodge DS0000025748.V361682.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): NMS 2: People using the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective residents can be assured they will get up to date information and appropriate assessments are being undertaken so residents will know their care needs have been identified and could be met in this care home. EVIDENCE: The statement of purpose and the residents’ guide were checked and found to contain inaccurate information - an oversight when it was being complied; these errors have now been corrected and the documents are ready for distribution to residents and other interested parties. The home receives a great deal of detailed information in advance of the admission of residents. For example a recent admission included assessments from a variety of professional agencies, nurses and staff from the previous placement. This enabled the home to make a thorough assessment of the individual – although this may not guarantee the placement will be successful in the longer term but a trial period is offered to ensure both the home and the resident have made the right choice. Areas of strength include the detailed assessments drawn up in preparation for an admission and matters that previously required improvement, the statement of purpose and residents’ guide up to date, are now much more informative and include all the points listed in the Schedules to the Regulations. So this section, about choice, is assessed as good. Alice Lodge DS0000025748.V361682.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 6, 7, 8 and 9: : People using the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents know their needs are reflected in individual care plans for which they have been consulted so they can make choices and be supported in taking appropriate risks. EVIDENCE: Residents are involved in the development of their care plans and sometimes they sign up to secondary care contracts to address particular issues. To confirm this we checked a number of case files for both long term residents and those newly admitted; we also interview residents and spoke to the staff on duty. Residents have been involved in all stages of the care planning process including visits to the home to agree what support will be needed and to draw up ‘contracts of care’. Staff understand the importance of residents being supported to take control of their own lives but also know that some residents take inappropriate risks with their own help and wellbeing and so they will need support from staff to make decisions that will not affect their mental health and well being. The care plans whilst very detailed are very bulky documents including both day to day information and lengthy Alice Lodge DS0000025748.V361682.R01.S.doc Version 5.2 Page 10 background material. It is recommended the files be split to make the day to day notes more accessible to staff and the residents themselves. The plans are written in plain language, and are easy to understand and looks at all areas of the resident’s life. Staff have the skills and ability to support and encourage residents to be involved in the ongoing development of their plan. A key worker system allows staff to work on a one to one basis and contribute to the care plan for the individual. The care plan is a working document reviewed regularly involving the person and their representatives if agreed. It is kept up to date and focuses on how individuals will develop their skills and considers their future aspirations. So we found for example that several residents are attending centres where they can develop skills for life including activities such as shopping and cooking but also more aspirational activities, like painting, where they will be able to use their skills when looking for employment - as several residents were. Each care plan includes risk assessments, which is reviewed regularly. Management of risk is positive addressing safety issues whilst aiming for better quality of life. Whilst risks are known we find that their appears to be inadequate supervision of residents in respect of those risks such as imbibing alcohol in an uncontrolled manner or making use of community resources such as charity shops (e.g. residents removing goods from the home to barter for other goods). We note that in some instances limitations need to be agreed with residents and the home tries, but does not always succeed in getting resident’s cooperation to reduce risks. Where limitations are in place, the decisions have been made with the person and are recorded, including any contingency plans. For new residents the trial period will be used for both the home and the resident to make choices about whether Alice Lodge is an appropriate placement – which is not always the case because some residents will not accept limitations that are in their best interests. There is information in place, for example in the resident’s Guide, to ensure that people using the service are informed of their rights to confidentiality. Individuals understand when staff may have to share personal information, for example with their local psychiatric services, and can access advocacy services for support. The home ensures that residents are consulted on a regular basis to gather information about their satisfaction. Whilst the documentation is good in the next section, about lifestyle, we explain that the diary notes, the evidence for daily activities and how the plans are put into practice, is somewhat limited. Areas of strength include the involvement of residents in their own plans for care; but we find residents aren’t being given enough support to act upon those plans of care; to assist staff in following care plans we recommended that the case files be split to make them more accessible to residents. This section, about recording need and choices, is assessed as good. The issues of support and staffing levels are addressed in other sections of this report. Alice Lodge DS0000025748.V361682.R01.S.doc Version 5.2 Page 11 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): NMS 11 to 17: : People using the service experience adequate outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can be assured that the home will offer the opportunity for personal development and to lead as active a lifestyle as they wish. They will be encouraged to maintain social and family contacts and will be offered suitable meals. EVIDENCE: The proprietor of Alice Lodge has a strong commitment to enabling residents to develop their skills, including social, emotional, communication, and independent living skills. So, individuals are supported to identify their goals, and work towards achieving them. Residents told us “we go out to day centres where we learn to shop and cook”; “We go shopping every day” and “I like to go out for a walk”. When we have spoken to visitors they often commend the home for its good work. For many residents the chosen lifestyle is to spend the day relaxing and pottering around the home undertaking small domestic chores. A lot of residents choose to smoke and so the home has a small smoking room. Alice Lodge DS0000025748.V361682.R01.S.doc Version 5.2 Page 12 When we spoke to residents they told us that they have the opportunity to develop and maintain important personal and family relationships. Residents told us how they keep in touch by receiving visitors in the home or by going out to meet old friends and family. It is intended that staff promote the individual rights and choice, whilst protecting of residents from unwarranted risks. Staff should support residents to make informed choices. Sadly, some residents resist this sort of support and advice – for example some residents resist support in looking after their bedroom whilst others are unable to cooperate with restricted contacted with old friends. Residents are involved in some limited daytime activities of their own choice and according to their individual interests and capability; they have been involved in the planning of their lifestyle and quality of life and usually sign their care plans. Where appropriate education and occupation opportunities are encouraged, supported and promoted. Residents told us “we are booked onto courses at Carshalton College, we will be doing cooking”. Residents also told us that they are looking for voluntary work and even paid employment where this is possible. Despite this apparently positive picture painted by residents in fact their daily notes, (the record drafted by staff intended to show their daily activities and how their care plans are being worked upon), shows that staff are taking little initiative to work upon those care plans. Entries such as ‘slept well’, ‘had a pleasant day’, ‘went for walk’, and so forth, they showed no positive interventions by staff. During our visit we noted that many residents get up early then retire back to bed so as we toured the home many residents were still a asleep in bed. We also found that a number of incidents such as the recent overflowing toilet; hoarding beer cans, resident giving away the home’s bed linen, resident using a hammer to break a window and so forth. This indicates to the Commission that there are insufficient staff on duty to supervise residents and to help them work upon their care plan objectives. During the visit it we were advised that the chef will develop his role to provide training for residents to develop skills for daily living. Residents were seen to helping in the kitchen and how confident residents were in the kitchen. As the kitchen is being locked when no staff are present (for safety and hygiene reasons we were told) we suggested a small kitchen bar is installed in the dining area so residents can help themselves to tea/coffee and snack foods. Areas of strength include the residents’ and visiting professionals’ opinions that they find life in Alice Lodge most agreeable and residents who want to be more independent are being encouraged to be so but this appears to mean that residents are often left to occupy themselves without enough support or guidance; we require staffing levels to be reviewed and staff are to supported and directed by the manager to work with residents on their individual care plans. Since there is limited evidence this is happening at present this section, about lifestyle, is assessed as adequate. Alice Lodge DS0000025748.V361682.R01.S.doc Version 5.2 Page 13 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): NMS 18,19 and 20: : People using the service experience adequate outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents cannot always be assured that Alice Lodge can provide personal, emotional and healthcare support as outlined in their care plans. Medication is mostly being safely handled to ensure the well being of residents but lapses were observed. EVIDENCE: Personal healthcare needs including specialist mental health, are clearly recorded in each resident’s plan; they give a comprehensive overview of their health needs and act as an indicator of change in health requirements. The Statement of Purpose and the Residents’ Guide details the specialist treatments the home can deliver with a commitment to individualised care planning, and refer to the skills and ability of the staff group. So, for example, in Alice Lodge the home offers support to adults with enduring mental health problems. Personal support is however staff do not appear to be responsive to the varied and individual needs and preferences of the residents as outlined in their various care planning documentation. The delivery of personal care should be individual and flexible, consistent, reliable, and person centred but in reality the daily notes, and our observations of residents during the course of our Alice Lodge DS0000025748.V361682.R01.S.doc Version 5.2 Page 14 day-long visit indicate that residents tend to occupy themselves, going for walks, sitting in the main lounge, smoking in the small smoking room - and not infrequently retiring to bed during the day; some are engaged in risk-taking activity such as consuming alcohol even in the early morning. The daily notes merely reflect this activity with no indication, that we saw, that staff are taking the initiative and leading activities in accordance with the prescribed care planning. In respect of diversity and respecting of residents’ cultural, ethnic, gender, beliefs and other preferences the home employs both male and female staff to give choice about gender but there is little choice about staff sharing the same cultural background because none of the staff share a similar background to residents who are mostly, though not all white/English. Residents have access to healthcare and remedial services, staff make sure that those residents who are fit and well enough are encouraged to be independent, have regular appointments and visit local health care services. Residents at present appear not to need any specific aids and equipment (and the home is not well adapted to wheelchair users but no residents have need of wheelchairs). Staff support residents in daily living skills but this does require specialist equipment. Staff has access to training in health care matters and are encouraged and given time to attend courses on specialist areas of work. The aims and objectives of the home, as outlined in the Statement of Purpose, reinforce the importance of treating individuals with respect and dignity. The home has an efficient medication policy supported by procedures and practice guidance, but staff do not always maintain the high standard of recording required if residents are to be safe in this area. We checked a sample of the medication records and found they are mostly completed, but we did find errors in accounting for medicines. It appears the errors were mathematical rather than an error in administration but nevertheless it could have serious consequences for the resident if either no medicine was given or a second dose administered as a result of inaccurate recording. The general manager, who was on site for part of the inspection, confirmed that it is his role to undertake regular management checks to monitor compliance and he agreed that closer attention was required by himself and the (acting) manager when they audit medication. Areas of strength include the good links the home has with the psychiatric teams and the links they have with other health care professionals but the apparent lack of any evidence of a link between the care planning and the actual day to day support by staff to enable residents to work on those care plans. Errors were also noted in recording medicines. So this section about health and social care is assessed as adequate. Alice Lodge DS0000025748.V361682.R01.S.doc Version 5.2 Page 15 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): NMS 22 and 23: : People using the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Arrangements are in place for residents 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 their views are taken into account. Policies and procedures to protect vulnerable residents are in place and staff interviewed were aware of them. So residents know their concerns will be listened to and they will be protected from harm. EVIDENCE: We spoke to residents, to staff and the management team to evaluate this section. We also checked relevant records including the record of complaints, residents’ case files and staff files. We also take account of any strategy meetings that have been held under the local authority’s ‘safeguarding adults’ procedures. There has been one such investigation in recent months and this is still ongoing at the time of reporting. The home has an open culture that allows residents to express their views, and concerns in a safe and understanding environment. Residents confirmed this by telling us that they often meet the proprietor, Mrs Dankyi – whom everyone knows as ‘Alice’. When they have concerns they “tell the staff, our keyworker”. We saw residents calling into the small office and asking for help and advice and sharing their worries with staff - who responded very patiently to them. Residents and others involved with the service say that they are happy with Alice Lodge, and it was evident they feel safe and well supported by an organisation that has their protection and safety as a priority. The service has a complaints procedure that is clearly written and easy to understand. The complaints procedure is supplied to everyone living at the home and is on Alice Lodge DS0000025748.V361682.R01.S.doc Version 5.2 Page 16 display in the home. Residents and others involved with the home understand how to make a complaint and are clear about what will happen if a complaint is made. The manager states that they keep a record of complaints but when we checked the record book there has been just one entry for the last twelve months – suggestive but not proof of lack of recording rather than a lack of complaints in this type of service where residents are often heard to be grumbling about something. We recommend that the complaint book is used more actively to note even small matters of concern so residents can be assured their voice is listened to and will see for themselves in what manner their concerns are addressed – giving them more confidence to complaint if serious issues arise in the future. It also gives residents the opportunity practice speaking out in an acceptable manner when using services in the community. The policies and procedures for Safeguarding Adults are available and give clear specific guidance to those using them. The home has made use of the procedures in recent incident and has demonstrated a willingness to cooperate with local managers in investigating concerns about the well being of residents. So staff know when incidents need external input and who to refer the incident to. Staff from the home always attend meetings or provide information to external agencies when requested. Areas of strength include the openness of the home to listen to concerns and act upon them. No matters requiring improvement arise but a recommendation is made to make better use of the compliant record. So this section, about complaints and protection, is assessed as good. Alice Lodge DS0000025748.V361682.R01.S.doc Version 5.2 Page 17 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): NMS 24 and 30: : People using the service experience adequate outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Alice Lodge has been refurbished throughout with residents input in terms of choice of the redecorations in their bedrooms and communal areas. So it is for the most part a safe and homely environment for residents and in most areas it is kept in a clean and tidy condition for the benefit of residents. EVIDENCE: We toured of the premises including all the communal areas and some of the residents’ bedrooms. The refurbishment is good and is mostly in good repair; with the exception of the dining room ceiling and bedrooms above - which is being repaired after suffering water damage. The residents told us how they liked the house and that their bedrooms are as they wish them to be, so some are rather bare others rather cluttered, and that they feel ‘at home’ in Alice Lodge. The cleaners keep the home clean and odour free. But one area still requiring further attention is the smoking room, which is located towards the back of the premises. The walls are badly finished, there are no curtains and poor standard of chairs. Other areas of maintenance also need attention including light bulbs, broken drawers, broken window. A better system is needed to identify damage, this includes staff being alert to problems such as lights not working, reporting it and repairs then undertaken effectively and without undue delay. Overall quality in this area remains only adequate. Alice Lodge DS0000025748.V361682.R01.S.doc Version 5.2 Page 18 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): NMS 32, 33, 34 and 35: : People using the service experience adequate outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The staff team do hold a variety of qualifications, which ensures that residents could be supported appropriately but they are insufficient in numbers to be able to do so. The recruitment policy and practices have improved so the wellbeing and interests of residents are being protected. EVIDENCE: We have inspected this home several times since it was thoroughly refurbished and there are many new residents in Alice Lodge, they have told us they very have confidence in the staff team that cares for them; they say for example, “Staff here are very good, I like them” and “they (staff) are very nice people”. One resident said “More support is needed … staff support us as much as possible” and “The home offers a high level of care”. Although there is detailed staff roster on display as required it indicated that there were at times insufficient staff on duty. Although the proprietor Mrs Dankyi contends that there are enough staff to meet the needs of residents it was evident from the number and range of incidents such as a resident blocking a toilet; resident hoarding beer cans; residents consuming alcohol from early in the morning; residents bartering with the home’s linen and many residents merely retiring to bed after breakfast. We also noted in earlier sections that the daily notes gave no indication that there were enough staff to Alice Lodge DS0000025748.V361682.R01.S.doc Version 5.2 Page 19 follow the care plans drawn up for each residents – instead they spent the day freely wandering around town, in bed, smoking or watching television. We conclude there are insufficient numbers of staff to supervise and support residents to pursue their plans of care. The home now employs ancillary staff to do the main cooking and cleaning and this should give care staff time to work with and support residents including any support they might need in cooking and cleaning as part of learning life skills. This approach to the main ancillary duties is commended but is not reflected in staff being able to spare more time to work directly with residents who seem to occupy themselves without direction from staff. Staff members undertake external qualifications beyond the basic requirements – so, for example, the new manager who was interviewed by the inspector had a clear understanding of the mental health needs of the residents and was well as demonstrating she was well informed about care issues including health and safety, protection of vulnerable adults, food hygiene and so forth. Staff tell us that they have a contract and a job descriptions clearly defining their the roles and responsibilities. The service has satisfactory recruitment procedures and having checked a sample of staff files over the course of several visits to this home we see that this procedure is being followed in practice in order to deliver of good quality services and for the protection of individuals. Staff recruited confirm that the service was clear about what was involved at all stages and was robust in the following of its procedure – so for example the a member of staff who has recently joined the home has undergone all the required check including a police [CRB] check and reference checks. We checked by speaking to staff and by checking records to confirm that staff meetings take place regularly and that staff supervision sessions are regular. Areas of strength include a dedicated and loyal staff team that seem very popular with the residents; staff are recruited and trained appropriately. Matter requiring improvement include the need for the proprietor to review and increase staffing levels so as to more fully meet the needs of residents; this section, about staff, is assessed as adequate. Alice Lodge DS0000025748.V361682.R01.S.doc Version 5.2 Page 20 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): NMS 37, 39, 41 and 42: : People using the service experience adequate outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Alice Lodge has been without a registered manager since the summer of 2003 so residents cannot be assured that the home is consistently managed, competently led and well managed at all times. Administration is adequate and most areas are safe although some safety issues were identified and need correction if residents are to be safeguarded. The acting manager does not always ensured there are adequate number of staff on duty to met the needs of residents at all times. EVIDENCE: Of critical importance to the continued safe running of this home is for a permanent manager to be registered. Since 2003 the owner has employed a number of prospective managers who have each resigned before completing the registration process with the Commission. In April 2008 when we visited yet another person has been recruited to the post but they have not yet completed the registration process. Alice Lodge DS0000025748.V361682.R01.S.doc Version 5.2 Page 21 Despite this serious issue the home is managing to meet many standards and by now residents, and staff, seem to have got used to changing leadership and are very loyal towards this latest manager. The owner, Mrs Dankyi, takes a ‘hands-on’ approach to the running of her homes and knows all the residents very well; she is a familiar figure, calling into her care homes most days. Whilst the day to day running should be in the hands of a competent person on site, her involvement at this level has provided some consistency and continuity although on this occasion she had rewritten the manager’s proposed duty roster and reduced the number of staff on duty to the detriment of residents’ care. Even the General manager said he was unaware of the changes made to the staff roster. The office in this unit is very small indeed and so filing tends to be little chaotic but those records we checked included the visitors’ book; complaints; accidents; resident files; staff files, kitchen records; fire safety records and a record of the owner’s monthly visits (known as the ‘Regulation 26 visits’). They are mostly adequately maintained. Some files had indexes others did not so checking the files could not be undertaken very efficiently. There were errors in the medication records and residents’ money record – suggesting that auditing by the manager and General manager is not as thorough as it should be. In respect of fire safety, several fire door were wedged open including the smoking room and kitchen door and so compromised the rest of the home. A member of staff was unsure about the correct procedures when a fire discovered and had not had a fire drill in this home. Areas of strength are include the residents’ opinion that this is very good home but without a registered manager for 4 years and with several safety matters requiring attention this section is assessed as adequate; as other key areas are also assessed as adequate the overall assessment of the home is adequate and gets a one star rating. Alice Lodge DS0000025748.V361682.R01.S.doc Version 5.2 Page 22 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 3 3 X 4 X 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 2 25 X 26 2 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 2 12 3 13 2 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 x 2 X 3 X 2 2 X Alice Lodge DS0000025748.V361682.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes 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. Standard 1. YA37 Regulation 8(1) Requirement Manager: The provider must make application to register a manager for this home without unreasonable delay. This remains outstanding from 30/8/06 and 30/12/06 a revised timescale is given as an application is with the Commission Supervision of residents: Residents must receive adequate supervision so as to minimise risks to their health and welfare as well reducing risks to the home’s property. Medicines: the home must ensure that medicines are administered and recoded safely and are effectively audited to ensure the welfare of residents. Décor: The premises must be maintained in good order and decorated to a reasonable standard. Residents caused considerable damage to the property and it is under repair but was not finished at the time of inspection. Décor: The smoking room must be maintained in good order and decorated to a reasonable DS0000025748.V361682.R01.S.doc Timescale for action 30/06/08 2 YA9 YA11 YA13 YA18 12(1)b 30/06/08 3 YA20 13(2) 30/06/08 4 YA24 23(2)b 30/06/08 5 YA24 23(2)b 30/08/08 Alice Lodge Version 5.2 Page 24 standard. This requirement is restated because residents are still not satisfied with the partial redecoration. 6 YA26 23(2)m Bedroom storage space: Each bedroom must provide a suitable lockable unit for residents to store valuables in their rooms unless a written risk assessment indicates otherwise; this is so all residents have a place to store personal property safely. Staffing levels: the proprietor must review staffing levels for all parts of the day so as to be able to demonstrate that the needs of residents are being met to ensure residents get adequate levels of support and supervision. Staff training: all staff including the manager must receive adequate training in mental health and mental health law so they know what parts of the Mental Health Act apply to the residents in this home. Records: All records required to be maintained in the care must be accurate; including medication and money records so that residents can be assured their medicines and money are being managed properly. Fire safety: all fire doors must be kept shut unless held open by a suitable safety device; this is to protect resident from the spread of fire. Fire safety: all staff must receive fire training including practice fire drills so that they know the procedures for protection and supporting residents in the event if a fire. 30/06/08 7 YA32 18 30/06/08 8 YA35 18 30/06/08 9 YA41 17 30/06/08 10 YA42 23 30/06/08 11 YA42 23 30/06/08 Alice Lodge DS0000025748.V361682.R01.S.doc Version 5.2 Page 25 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 YA6 Good Practice Recommendations Resident case files: It is recommended that the case files are better arranged so that residents and staff can manage them more readily; for example the latest care plan/s and daily notes could be made much more accessible to staff, and the residents to whom they apply, so that care plans are reflected in staff day to day practice and so that the daily notes reflect work towards meeting residents’ personal goals. Alice Lodge DS0000025748.V361682.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Alice Lodge DS0000025748.V361682.R01.S.doc Version 5.2 Page 27 - 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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