Inspection on 22/11/07 for Alice Lodge

This inspection was carried out on 22nd November 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 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 11 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 02/05/06

Alice Lodge 15/12/05

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 Key Unannounced Inspection 22 November 2007 10:30 nd Alice Lodge DS0000025748.V347550.R02.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.V347550.R02.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.V347550.R02.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 Post Vacant Care Home 16 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (16) of places Alice Lodge DS0000025748.V347550.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 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 and a separate dining room. The home has 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 limited parking to the front. Fee as at November 2007 were from £400 to £960. Alice Lodge DS0000025748.V347550.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of a key inspection a site visit was made to Alice Lodge on 22nd November 2007. Residents on the premises were given the opportunity to meet with the inspector. Staff were interviewed including ancillary staff. The Owner, Mrs Dankyi was present for part of the inspection and so was the area manager, but the acting manager and deputy were both absent on the day of inspection and so a manager from another of the group of home was present to assist in the day to day running of the home. We also checked a wide range of documents including care files and staff record plus the accident book, the incident book, fire records and kitchen records. Questionnaires were distributed to the residents, staff and visitors and any feedback noted. We also took note of information provided to the Commission during 2007. What the service does well: What has improved since the last inspection? What they could do better: The home has been without a registered manager since Mrs Dankyi said she intended to appoint one in June 2003. Several acting managers have been in post but moved on before their registration was completed. There were a number of environmental problems including the smoking room that was in a poor state of repair; residents were asking for “the walls to be cleaned and new furniture that is safe for us when we smoke in here”. Some fire extinguishers had not been checked this year when others had. Three fire doors were wedged open. Alice Lodge DS0000025748.V347550.R02.S.doc Version 5.2 Page 6 The staff records did not demonstrate clearly enough what checks had been made before staff were employed and in one instance the police check [CRB] was missing although the proprietor assured the inspector that the check had been made and the form returned to the company before this employer was allowed to work on the premises and the member of staff had already confirmed this point. The staff duty roster did not reflect the staff on duty that day; both the manager and deputy were absent and although they had been replaced by an acting manager the revised arrangements were not reflected in the duty rota. The owner’s visits, called regulation 26 reports, were not being completed properly; they were infrequently recorded and inadequate in detail. One resident thought a craft room or craft area would be helpful and this suggestion is passed on to the organisation. As the kitchen is locked when the chef or other staff are not present a utility area in the dining room for tea/coffee making was also mooted. 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.V347550.R02.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.V347550.R02.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 1 and 2: Quality in this outcome area adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents cannot be assured they will get up to date information but adequate 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 be out of date; for example the name of the manager was wrong and the address of the Commission was not given. 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 but matters requiring improvement include the need to keep the statement of purpose and residents’ guide up to date and comprising all the pints listed in the Schedules to the Regulations. So this section, about choice, is assessed as adequate. Alice Lodge DS0000025748.V347550.R02.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: Quality in this outcome area good. This judgement has been made using available 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: Staff involve individuals in the planning of care that affects their lifestyle and quality of life and the level of support the will need. 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 background material. It is recommended the files be Alice Lodge DS0000025748.V347550.R02.S.doc Version 5.2 Page 10 split to make the day to day notes more accessible to staff and the residents themselves. The care plans are person centred and are agreed with the individual. The plans are written in plain language, is 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 activi9ties 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. 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. Areas of strength include the involvement of residents in their own plans for care; 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. Alice Lodge DS0000025748.V347550.R02.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: Quality in this outcome area good. This judgement has been made using available 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”. During this site visit staff from the local Mental Health services were visiting residents to arrange an exhibition of artwork by patients and residents. These visitors commended 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.V347550.R02.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. The practice of staff promotes individual rights and choice, but also considers protection of individuals, supporting people 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 daytime activities of their own choice and according to their individual interests and capability; they have been fully involved in the planning of their lifestyle and quality of life. Where appropriate education and occupation opportunities are encouraged, supported and promoted. So in Alice Lodge 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. Residents are accessing and enjoying the opportunities available in their local community, including public transport, library services, the local pub, and local leisure facilities. Here is large supermarket opposite Alice Lodge and residents are regular customers there. Residents are regularly involved in the domestic routines of the home, they take responsibility for their own room; they are consulted about menu planning and cooking meals, making sure that they are able to enjoy the food they prefer and like – the chef confirmed it was part of his role to speak to residents about meals and menus. So the menu is varied with a number of choices including some healthy options. It includes a variety of traditional dishes and some that encourage individuals to try new and sometimes unfamiliar food, for example the new chef has been offering Mediterranean style food to encourage a more healthy diet. During the visit it was good to see how accommodating the chef is in supporting residents to help in the kitchen and how confident residents were in the kitchen. Staff advised us that residents, who are able to prepare meals for themselves, or wish to learn, are given individual support in the kitchen as part of a rehabilitation programme. As the kitchen is being locked when no staff are present (for safety and hygiene reasons were are told) we suggest 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; and as only one suggestion is made, to install a kitchen bar for residents, this section, about lifestyle, is assessed as good. Alice Lodge DS0000025748.V347550.R02.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: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be assured that Alice Lodge can provide personal, emotional and healthcare support as they may require. Medication is being safely handled to ensure the well being of residents. 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 responsive to the varied and individual needs and preferences of the residents. The delivery of personal care is individual and is flexible, consistent, reliable, and person centred; one resident mentioned he gets time “to talk to his key worker – and has been helped to registered with a local college to do cooking”. Staff respect privacy and dignity and are sensitive to changing needs. The service listens and responds to individuals’ choices and decisions about who Alice Lodge DS0000025748.V347550.R02.S.doc Version 5.2 Page 14 delivers their personal care, 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 as none of the staff are white/English like most residents. Residents are supported and helped to be independent and can take responsibility for their personal care needs – this includes some risk-taking as some residents have mental health problems that may affect the way they lead their lives. 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, which staff understand and follow. We checked a sample of the medication records and found they are fully completed, contain required entries, and are signed by appropriate staff. The area manager who was onsite for part of the inspection confirmed that it is his role to undertake regular management checks to monitor compliance. Areas of strength include the personal and health care provided and as no matters requiring improvement arise this section, about care, is assessed as good. Alice Lodge DS0000025748.V347550.R02.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: Quality in this outcome area good. This judgement has been made using available 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 visitors, 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.V347550.R02.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 had no entries for the last twelve months – more indicative of lack of recording rather than a lack of complaints in this type of service. 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. There are a low number of referrals made as a result of lack of incidents, rather than a lack of understanding about when incidents should be reported. The outcomes from any referral are managed well and issues resolved to the satisfaction of all involved. Training of staff in the area of protection is regularly arranged by the Home. Other training around dealing with physical and verbal aggression is also made available to staff as needed. 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.V347550.R02.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: Quality in this outcome area adequate. This judgement has been made using available 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 a safe and homely environment for residents and it is kept in a clean and tidy condition for the benefit of residents. EVIDENCE: The Inspector made a tour of the premises that included all the communal areas and some of the residents’ bedrooms. Although the standard of the refurbishment is good and in mostly in good repair; with the exception of the dining room ceiling which is about to be repaired after suffering moisture damage. The residents all told us how they liked what had been done and that their bedrooms are as they wish them to be and that they feel ‘at home’ in Alice Lodge. They confirmed that they have been able to choose their decorations and personal effects. Most areas were odour free, clean and tidy. But one area requiring urgent attention is the smoking room, which is located towards the back of the premises. The walls were stained; the chairs old and worn, there was no light shade and a fire extinguisher was holding open the door. Residents said they would “like some new chair, these are no good”. Residents also said they, “need a new iron” to iron their clothes. Overall quality in this area remains adequate. Alice Lodge DS0000025748.V347550.R02.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, 34 and 35: Quality in this outcome area good. This judgement has been made using available evidence including a visit to this service. The staff team do hold a variety of qualifications, which ensures that residents can be supported appropriately. The recruitment policy and practices have improved so the wellbeing and interests of residents are being protected. EVIDENCE: Residents 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 people”. Although there is detailed staff roster on display it did not show the changes of staff for this week so when neither the (acting) manager nor deputy were on duty their replacements were no indicated on the published duty roster. On the day a manager from another of the proprietor’s homes was covering the manager’s shifts and the area manager was also doing some shifts to ensure continuity. The home now employs ancillary staff to do the main cooking and cleaning and this gives care staff time to work with and support residents including any support they might need in cooking and cleaning for themselves. This approach to the main ancillary duties is commended and is reflected in staff being able to spare more time to work directly with residents who tell us they give a lot of support now. Alice Lodge DS0000025748.V347550.R02.S.doc Version 5.2 Page 19 Staff members undertake external qualifications beyond the basic requirements – so, for example, the member of staff 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. There are appears to be enough staff available to meet the needs of the people using the service, with more staff being available at peak times of activity and if necessary staff from the “Alice” group of homes can be called to help - as they did on the day we were visiting. The service has an adequate recruitment procedure and having checked a sample of staff files 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. No matters requiring improvement arise, so this section, about staff, is assessed as good. Alice Lodge DS0000025748.V347550.R02.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: Quality in this outcome area poor. This judgement has been made using available 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 competently led and well managed at all times. Administration is adequate and most areas safe although some safety issues were identified and need correction if residents are to be safeguarded. 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. At present, in November 2007 when we visited, yet another person has been recruited to the post but she was not available to manage the home when we were visiting. The deputy manager was also absent; the area manager (who has been covering the day Alice Lodge DS0000025748.V347550.R02.S.doc Version 5.2 Page 21 to day management of the home) was also away for most of the day - so as a fourth option the home was being supported by a manager from another unit. Despite this serious issue the home is managing to meet most standards and by now residents, and staff, have got used to changing leadership. The owner, Mrs Dankyi, takes a ‘hands-on’ approach to the running of her homes and knows all the residents very well; she is familiar figure calling into her homes each day and overseeing even basic detail such as weekly shopping. Whilst the day to day running should be in the hands competent person on site her involvement at this level has provided some consistency and continuity. 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. There were however a number of deficiencies such as the monthly visits, there have been none recorded since July 2007 and the notes of visits up to that date are too brief and give no indication the extent of the checks made by the person visiting. Whilst the proprietor advised us that all staff checks had been made before employing new member of staff not all the files held the documentation – references for example were missing and so was a Police [CRB] check. Some files had indexes others did not so checking the files could not be undertaken very efficiently. In respect of fire safety the record keeping was to an acceptable standard but not all of the fire extinguishers had been checked (or signed as checked) so they were out of date. One fire extinguisher was being used to hold open the door to the smoking room and so compromised the rest of the home. The kitchen door was wedged open at one point and another fire door was held open by carpet friction. 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 poor and therefore the overall assessment of the home is poor. Alice Lodge DS0000025748.V347550.R02.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 2 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 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 1 X 3 X 2 1 X Alice Lodge DS0000025748.V347550.R02.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. 1. Standard 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. Statement of Purpose: this document must be kept up to date including all the points listed in Schedule 1 so that residents and The Commission have accurate information about the home. Resident guide: this document must be kept up to date including all the points listed in Standard 1 so that residents have accurate information about the home. Décor: The smoking room must be maintained in good order and decorated to a reasonable standard. Hygiene: The smoking room must be kept clean. Furniture: chairs and other items of furniture must be fire resistant to modern standards and provide DS0000025748.V347550.R02.S.doc Timescale for action 30/01/08 2 YA1 6 (a) and 6 (b) 30/01/08 3 YA1 6 (a) and 6 (b) 30/01/08 4 YA24 23(2)b 30/01/08 5 6 YA30 YA24 23(2)d 23(2)c 30/01/08 30/01/08 Alice Lodge Version 5.2 Page 24 7 YA24 23(2)c 8 YA33 18(1)a 9 YA42 23(4) and 23(4A) 10 YA42 23(4) and 23(4A) 11 YA39 26 a comfortable setting for residents who choose to smoke. Equipment: Residents must be provided without suitable and undamaged equipment such as an iron so that they can maintain their independence. Staff duty roster: The staff rota must reflect who is actually doing shifts and no just projections so residents, other staff and visitors know who is working in the home. Fire safety: Fire equipment such as extinguishers must be tested at least annually so residents and staff know they are in good working order. Fire Safety Doors: All fire doors must be kept shut unless held open by suitable magnetic door holding device that responds to the fire alarm so residents are kept safe. Owner’s visits: the owner must ensure that the home is visited in accordance with Regulation 26, at monthly intervals, and a report supplied to the home and the Commission. This will ensure the owner is aware of issues in the home and can deal with them in a timely manner. 30/01/08 30/01/08 30/01/08 30/01/08 30/01/08 Alice Lodge DS0000025748.V347550.R02.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 2 3 Refer to Standard YA6 YA34 YA24 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. Staff files: It is recommended that the case files are better arranged so that staff and managers can manage them more readily. Residents suggested that it would help to have access to tea-making equipment and this suggestion is endorsed by the Commission perhaps in the form of tea bar in the dining room. Residents suggested a craft room would be helpful and again the Commission endorses this suggestion to encourage a wider range of in-house activities. 4 YA24 Alice Lodge DS0000025748.V347550.R02.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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. 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