Inspection on 16/06/05 for Angel Lodge

This inspection was carried out on 16th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Angel Lodge 23/02/09

Angel Lodge 05/06/07

Angel Lodge 04/10/06

Angel Lodge 19/10/05

Angel Lodge 25/05/04

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 Mayfield Road (12) 12 Mayfield Road Sanderstead South Croydon, Surrey CR2 0BE Lead Inspector James OHara Unannounced 16th June 2005 14:00 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 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 Stationary 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. Mayfield Road (12) G53-G53 S28130 MayfieldRoad12 unann V233516 160605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Mayfield Road (12) Address 12 Mayfield Road Sanderstead South Croydon Surrey CR2 0BE 020 8657 9046 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Rosina Beatrice Annan Mrs Rosina Beatrice Annan Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places Mayfield Road (12) G53-G53 S28130 MayfieldRoad12 unann V233516 160605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: A variation has been granted to allow two specified service users over the age of 65 to be accommodated until such time as their needs can no longer be met in the home. Date of last inspection 26/01/05 Brief Description of the Service: Mayfield Road is a 3-bedded home providing care for younger adults with a past/present mental illness. The house itself is roomy, well decorated and comfortable. It is situated in a residential street, close to a rail station and within reasonably easy reach of the centre of Croydon and its many community facilities. Each of the service users is provided with a single bedroom, and they share a bathroom. They also have free use of a large lounge, a very nice, newly refurbished kitchen, and a spacious rear garden. Mayfield Road (12) G53-G53 S28130 MayfieldRoad12 unann V233516 160605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home was inspected under the National Minimum Standards. This unannounced inspection took place in the afternoon. Methods of inspection included a tour of the premises, discussion with two of the service users and the registered provider. Records examined included policies and procedures, training records, service user files, risk assessments and fire records. Previous requirements and recommendations were discussed with the registered provider. What the service does well: What has improved since the last inspection? What they could do better: As a result of this inspection one requirement and one recommendation have been set. The home could improve how it risk assesses and monitors self-medication. The registered provider said that plans to write up guidelines for monitoring service users who self medicate. The registered provider could risk assess and plan for the event of her not being present to administer medication. Mayfield Road (12) G53-G53 S28130 MayfieldRoad12 unann V233516 160605 Stage 4.doc Version 1.30 Page 6 The home keeps a weekly record of hot water temperatures on a calendar; this could be recorded in a hardback book. The registered provider plans to introduce Person Centred Plans; these will ensure that the service users are able to record achievements and plan for the future. The inspector would like to thank the service users, the registered provider and her son for their support on the day of the inspection. 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. Mayfield Road (12) G53-G53 S28130 MayfieldRoad12 unann V233516 160605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Mayfield Road (12) G53-G53 S28130 MayfieldRoad12 unann V233516 160605 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2. In the main the home provides prospective service users and their representatives with good information they need to make an informed decision about whether or not to use the service. The admission procedure is adequate to ensure a thorough assessment of prospective service users needs and aspirations are carried out before they move in. EVIDENCE: The registered provider has purchased a set of policy and procedure from a consultancy company this has helped improve the homes administration systems and structure. The home now has an admissions procedure as previously required. The registered provider was able to explain this procedure, this includes care management and medical assessments, visits to the home, overnight stays, trial periods and reviews. The registered provider said that the home does not except emergency placements. No service users have moved to the home since the last inspection. All service users have had their needs assessed by a care manager from their placing authorities. Mayfield Road (12) G53-G53 S28130 MayfieldRoad12 unann V233516 160605 Stage 4.doc Version 1.30 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 and 9. Generally service users have had individual risk assessments and risk management strategies carried out thus enabling them to participate in activities in the home and in the community with appropriate support. EVIDENCE: The current service users are capable individuals, and able to make most decisions independently. Two of the service users are able to manage their own finances, while the registered provider deals with the personal allowance of the third service user. The registered provider has obtained details of advocacy services and made these available to the service users as previously required. None of the service users have felt the need to contact an advocate however the registered provider said that the service users know they are available. Risk assessments were viewed for all service users as previously required. Risk assessments completed are around service users using the bath, stairs and going out alone. The registered provider plans to introduce Person Centred Plans; these will be examined at the next inspection. Mayfield Road (12) G53-G53 S28130 MayfieldRoad12 unann V233516 160605 Stage 4.doc Version 1.30 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15 and 17. Provision is made so that all service users attend appropriate social activities and become part of the local community. Appropriate arrangements are made so that service users have regular contact with their friends and families. EVIDENCE: The registered provider has encouraged a service user who previously did not wish to leave the home to attend a weekly photography group. The service user said that he enjoyed going out on the minibus to take pictures. The other service users like to use the community as they wish and risk assessments have been carried out for going out alone. The registered provider supports service users to maintain contact with family and friends. She has supported a service user to regain contact with family members from whom he had become estranged. Two service users said that they enjoyed meals offered in the home and both said that they are regularly consulted as to the menu. They are free to use the Mayfield Road (12) G53-G53 S28130 MayfieldRoad12 unann V233516 160605 Stage 4.doc Version 1.30 Page 11 kitchen, and each has an allocated space in a cupboard where they may keep some of their own provisions. There is also a designated fridge for the service users use. Mayfield Road (12) G53-G53 S28130 MayfieldRoad12 unann V233516 160605 Stage 4.doc Version 1.30 Page 12 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 standard(s) 19 and 20. Overall the arrangements for health care needs of the service users are good and they receive personal support in the way they prefer. With appropriate support service users can retain control over their own medication. EVIDENCE: The registered provider has tried to obtain an occupational therapist assessment of the home to ensure that it meets the needs of the elderly service users. This meets the previous requirement. One service user felt that he did not need an assessment and informed the occupational therapist department at Lambeth of this, however this can be reviewed again. The registered provider has written to Croydon Council regarding an occupational therapist assessment, they have in turn advised her to contact the service users care manager. The registered provider was in the process of doing this. The registered provider is the only person who administers medication. Two service users self medicate and one service user requires support. Medication is only administered in the mornings. The registered provider said that she regularly monitors the service users who self medicate. The registered provider said that plans to write up guidelines for recording and monitoring service users who self medicate. The registered provider must ensure that risk assessments are carried out for those service users that self medicate and that Mayfield Road (12) G53-G53 S28130 MayfieldRoad12 unann V233516 160605 Stage 4.doc Version 1.30 Page 13 a risk assessment is carried out and guidelines set in the event of the registered provider not being present to administer medication. The registered provider keeps a record of all medical and primary care appointments attended by each service user in the service user files as previously required. The home now has a file that includes copies of her and her family’s certificates and qualifications as previously required. Mayfield Road (12) G53-G53 S28130 MayfieldRoad12 unann V233516 160605 Stage 4.doc Version 1.30 Page 14 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 standard(s) 22 and 23. The home has suitable complaints and protection of vulnerable adults procedures in place to ensure the service users are so far as possible protected from abuse, neglect and/or harm. EVIDENCE: The homes has an appropriate complaints procedure this includes details of the Commission for Social Care Inspection. This meets a previous requirement. The registered provider does not employ staff so there is no necessity for the home to have a whistle blowing procedure in place. The home has a copy of Croydon Councils Protection Of Vulnerable Adults Policy and has used this as a guide to produce the homes procedure. Mayfield Road (12) G53-G53 S28130 MayfieldRoad12 unann V233516 160605 Stage 4.doc Version 1.30 Page 15 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 standard(s) 24 and 30. The home is suitable to the needs of the service users and is generally in good decorative order, clean and hygienic. EVIDENCE: The home is spacious and in good décor well maintained and suitable for purpose. Service users have access to all communal areas and each service user has their own bedroom. The home was free of odours, clean and hygienic. Mayfield Road (12) G53-G53 S28130 MayfieldRoad12 unann V233516 160605 Stage 4.doc Version 1.30 Page 16 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35. The registered provider does not employ staff in the home, the registered provider or occasionally a family member or an agency staff will be on duty in the home. Given the independence of the service users this is currently acceptable. EVIDENCE: The registered provider carries out the majority of the care duties, there are times when she is not available and family members help out or agency staff is employed. The registered provider has completed a rota indicating when her family or agency staff work in the home this meets a previous requirement. Mayfield Road (12) G53-G53 S28130 MayfieldRoad12 unann V233516 160605 Stage 4.doc Version 1.30 Page 17 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39, 41 and 42. The safeguarding of service users rights and interests have improved since the introduction of improved policies and procedures. This has also helped to improve the homes administration systems and structure. The development and introduction of systems that record the views of residents and relatives should increase confidence that their views influence the running of the home. The health and safety and welfare of service users continue to be promoted and protected by the improvements in record keeping and maintenance of the home. EVIDENCE: The registered provider is a qualified nurse, however she has not maintained her nursing registration. The registered manager is currently completing the Registered Managers Award at Bromley College. The registered provider has developed a system for recording improvements made in the home, the registered provider is developing service user, relatives and visitors questionnaires so that the home can obtain their views. Mayfield Road (12) G53-G53 S28130 MayfieldRoad12 unann V233516 160605 Stage 4.doc Version 1.30 Page 18 The registered provider has purchased a set of policy and procedures from a consultancy company this has helped improve the homes administration systems and structure. She has worked hard to ensure that these are employed in the home. The registered provider has sought and followed the advice of London Fire & Emergency Planning Authority for a fire procedure for the home 09/07/04. The registered provider keeps a weekly record of hot water temperatures on a calendar. It is recommended that hot water temperatures be recorded in a hardback book. The bedroom room of one service user who has a large music system is regularly checked to ensure that no unsafe alterations are made to the wiring. The registered provider provided a copy of the employers liability insurance as previously required. Mayfield Road (12) G53-G53 S28130 MayfieldRoad12 unann V233516 160605 Stage 4.doc Version 1.30 Page 19 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 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 3 x 3 Standard No 31 32 33 34 35 36 Score x x x x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Mayfield Road (12) Score x 3 2 x Standard No 37 38 39 40 41 42 43 Score 3 x 3 x 3 3 x G53-G53 S28130 MayfieldRoad12 unann V233516 160605 Stage 4.doc Version 1.30 Page 20 Yes. Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 20. Regulation 13 (2) and 13 (4) c. Requirement The registered provider must ensure that risk assessments are carried out for those service users that self medicate and that a risk assessment is carried out and guidelines set in the event of the registered provider not being present to administer medication. Timescale for action 31/08/05 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 42. Good Practice Recommendations It is recommended that hot water temperatures be recorded in a hardback book. Mayfield Road (12) G53-G53 S28130 MayfieldRoad12 unann V233516 160605 Stage 4.doc Version 1.30 Page 21 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 Mayfield Road (12) G53-G53 S28130 MayfieldRoad12 unann V233516 160605 Stage 4.doc Version 1.30 Page 22 - 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!