Inspection on 19/10/05 for Angel Lodge

This inspection was carried out on 19th October 2005.

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

The inspector found no outstanding requirements from the previous inspection report, but made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Angel Lodge 23/02/09

Angel Lodge 05/06/07

Angel Lodge 04/10/06

Angel Lodge 16/06/05

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 O`Hara Unannounced Inspection 19th October 2005 09:30 Mayfield Road (12) DS0000028130.V256593.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Mayfield Road (12) DS0000028130.V256593.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Mayfield Road (12) DS0000028130.V256593.R01.S.doc Version 5.0 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 Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs 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) DS0000028130.V256593.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 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. 16th June 2005 Date of last inspection 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) DS0000028130.V256593.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second unannounced inspection at the home this year. The inspection took place on a Wednesday morning. Methods of inspection included a tour of the premises, discussion with one of the service users and the registered provider. Records examined included policies and procedures, Statement of Purpose, Service Users Guide, service user contracts, 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: There was one requirement and one recommendation set at the previous inspection. The requirement has not been met. As a result of this inspection the requirement has been amended and broken into two requirements and a further five requirements have been set. The overall impression when visiting the home is that it is organised and service users are able to take part in appropriate activities both in and out of the home. However the homes Statement of Purpose, Service Users Guide and complaints policy are well out of date. The homes medication procedures also need to be amended. The home should move towards a Person Centred Plan appraoch so that ownership of the care plan is given to the individual service user. The registered provider needs to ensure that regular weekly checks of the homes fire alarm system is carried out. These checks should continue immediately. The inspector would like to thank the service users and the registered provider for their support on the day of the inspection. Mayfield Road (12) DS0000028130.V256593.R01.S.doc Version 5.0 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. Mayfield Road (12) DS0000028130.V256593.R01.S.doc Version 5.0 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 Mayfield Road (12) DS0000028130.V256593.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 5. Standard 2 assessed as met at the last inspection. The home should update the Statement of Purpose and Service Users Guide so that prospective service users and their representatives have all of the information they need to make an informed decision about whether or not to use the service. EVIDENCE: The homes Statement of Purpose and Service Users Guide were examined. The Statement of Purpose does not include all the information as required in Schedule 1 of the National Minimum Standards and the Service Users Guide was last reviewed in 2003. The registered provider said that the home does not except emergency placements. This information should be included in the Statement of Purpose. The registered provider must ensure that all information required in Schedule 1 of the National Minimum Standards is included in the Statement of Purpose. The registered provider must review and update the Service Users Guide. All service users have contracts that include terms and conditions, fees and charges, the homes responsibilities and the service users responsibilities. These have been agreed and signed by the service user and the registered provider. Mayfield Road (12) DS0000028130.V256593.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 and 8. Standards 7 and 9 assessed as met at the last inspection. The home should move towards a Person Centred Plan appraoch were the ownership of the care plan is given to the individual service user. EVIDENCE: One service users file was examined. There was evidence of regular annual placement reviews carried out by the service users care manager. At the last inspection the registered provider said that planned to introduce Person Centred Plans. These have not been introduced however the registered provider has completed care plans for the service users and reviews these on an annual basis. The care plans are not written in the first person and do not indicate the level of involvement of the service user in reviewing the plans. • • The registered provider must ensure that service user care plans are reviewed on a six monthly basis. That the care plan is completed in the first person. DS0000028130.V256593.R01.S.doc Version 5.0 Page 10 Mayfield Road (12) • • That the care plan indicates the level of involvement of the service user. That other relevant parties are invited to contribute to the plan for example key- workers at day services, advocates, relatives and care managers. That the care plan is signed as agreed by the service user. • Service users have signed to say that they do not wish to attend service user meetings in the home. The registered provider is developing a service user questionnaire in order to establish a consultation process so that service users can participate in the running of the home. This will be assessed at the next inspection. Mayfield Road (12) DS0000028130.V256593.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13 and 16. Standards 12, 13, 14, 15 and 17 were assessed as met at the last inspection. Provision is made so that all service users attend appropriate social activities and become part of the local community. EVIDENCE: On the day of the inspection one service user said that he goes to the day service once a week. He said he also goes shopping in Croydon with the registered provider. He said that he is happy living at the home and he has all the things he wants. It was noted that all service users were treated with respect during the period of the inspection. Mayfield Road (12) DS0000028130.V256593.R01.S.doc Version 5.0 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 the following standard(s): 20. The homes medication procedures need to be amended so as to ensure that service users are so far as reasonably practicable protected from harm. EVIDENCE: A requirement was set at the last inspection 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. This requirement has yet to be addressed. During a discussion it was agreed that this requirement is in two parts and should be broken into two requirements. The registered provider must ensure that risk assessments are completed for those service users that self medicate. The registered provider must ensure that a risk assessment is carried out and guidelines developed for the event of the registered provider not being present to administer medication. Mayfield Road (12) DS0000028130.V256593.R01.S.doc Version 5.0 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. The homes complaints policy should be updated so that service users have accurate information in case they wish to complain. Protection of vulnerable adults procedures are in place to ensure the service users are so far as possible protected from abuse, neglect and/or harm. EVIDENCE: The registered provider stated that there have been no complaints made at the home since the last inspection. The homes complaints procedure is out of date and includes details of the previous regulatory authority the National Care Standards Commission. The home complaints procedure must be updated and include the telephone number and details of the Commission for Social Care Inspection. 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) DS0000028130.V256593.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25 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. A chest of drawers in one of the service users bedrooms is broken. The registered provider must ensure that the chest of drawers in the service users bedroom is replaced or repaired. Mayfield Road (12) DS0000028130.V256593.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 and 34. Standard 35 was assessed as met at the last inspection. 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. The registered provider and her families Criminal Records Bureau Checks were observed at a previous inspection at the home. Mayfield Road (12) DS0000028130.V256593.R01.S.doc Version 5.0 Page 16 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 and 42. Standards 37, 39, 41 and 42 were assessed as met at the last inspection. The health and safety of the service users could be compromised if regular weekly checks of homes fire alarm system are not carried out. EVIDENCE: The registered manager is currently completing the Registered Managers Award at Bromley College. Hot water temperatures are now recorded in a hardback book as recommended at the last inspection. The homes weekly records of fire alarm checks indicate that the alarm system was last checked on the 13/06/05. The registered provider must ensure that the homes fire alarm system is checked on a regular weekly basis. Mayfield Road (12) DS0000028130.V256593.R01.S.doc Version 5.0 Page 17 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 2 X X X 3 Standard No 22 23 Score 2 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X 3 X X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 X X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 3 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Mayfield Road (12) Score X X 2 X Standard No 37 38 39 40 41 42 43 Score 3 X X X X 2 X DS0000028130.V256593.R01.S.doc Version 5.0 Page 18 No. Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA11. Regulation 4 (1). Requirement The registered provider must ensure that all information required in Schedule 1 of the National Minimum Standards is included in the Statement of Purpose. The registered provider must review and update the Service Users Guide. The registered provider must ensure that service user care plans are reviewed on a six monthly basis. That the care plan is completed in the first person. That the care plan indicates the level of involvement of the service user. That other relevant parties are invited to contribute to the plan for example key- workers at day services, advocates, relatives and care managers. That the care plan is signed and agreed by the service user. The registered provider must ensure that risk assessments are completed for those service users that self medicate. The registered provider must ensure that a risk assessment is DS0000028130.V256593.R01.S.doc Timescale for action 31/12/05 2. 3. YA11. YA66. 5 (1). 15(1)& 5(2)b,c&d 31/12/05 31/12/05 4. YA2020. 13 (2). 31/12/05 5. YA2020. 13 (4) c. 31/12/05 Mayfield Road (12) Version 5.0 Page 19 6. YA2222. 22 (7). 7. YA2424. 16 (2) c. 8. YA4242. 23 (4) a. carried out and guidelines developed for the event of the registered provider not being present to administer medication. The home complaints procedure must be updated and include the telephone number and details of the Commission for Social Care Inspection. The registered provider must ensure that the chest of drawers in the service users bedroom is replaced or repaired. The registered provider must ensure that the homes fire alarm system is checked on a regular weekly basis. 31/12/05 31/12/05 19/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Mayfield Road (12) DS0000028130.V256593.R01.S.doc Version 5.0 Page 20 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) DS0000028130.V256593.R01.S.doc Version 5.0 Page 21 - 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!