Inspection on 14/04/08 for Colney Lodge

This inspection was carried out on 14th April 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Colney Lodge 24/02/09

Colney Lodge 30/05/07

Colney Lodge 18/07/06

Colney Lodge 14/02/06

Colney Lodge 28/12/05

Similar services:

Chesham House

Argyll House

Dorset Lodge

Acacia House

Falcon House

Dial House Nursing Home

Cromwell Avenue (9)

Abbey Lodge

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

CARE HOME ADULTS 18-65 Colney Lodge 323 High Street London Colney Herts AL2 1ED Lead Inspector Jeffrey Orange Unannounced Inspection 14th April 2008 08:00 Colney Lodge DS0000060637.V362233.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 Colney Lodge DS0000060637.V362233.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. Colney Lodge DS0000060637.V362233.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Colney Lodge Address 323 High Street London Colney Herts AL2 1ED 07766 066307 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) colneylodge323@yahoo.co.uk Colney Lodge Limited Manager post vacant Care Home 2 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (2) of places Colney Lodge DS0000060637.V362233.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: There are none Date of last inspection 30th May 2007 Brief Description of the Service: Situated in the centre of London Colney, Colney Lodge is an end-of-terrace property that has been converted and adapted to enable it to provide a home to two younger adults who have a mental health disorder. There are in fact three bedrooms located on the first floor, with two reception rooms and a conservatory on the ground floor. There is an enclosed back garden and the front area is open plan. Beyond the back fence, there is car parking available. There is a shopping complex about a mile from the home and the wide range of facilities offered by the city of St Albans are located relatively close by. Copies of the home’s Service User Guide and Statement of Purpose, together with a copy of the last inspection report by the Commission for Social Care Inspection (CSCI) are available in the home for current or prospective service users. Weekly charges are from £750 - £780. The individual service user pays for personal toiletries, newspapers and dental or chiropody charges if they apply. These charges were confirmed on 14/04/2008 Colney Lodge DS0000060637.V362233.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. This unannounced inspection site visit took place over the course of a morning, starting at 8 am. During the inspection it was possible to speak to one of the two people currently living in Colney Lodge and to the proprietor who currently manages the service in the absence of a registered manager. Some key records were seen, including assessment and care plan documentation, medication records and financial records for monies held on behalf of one person living in Colney Lodge and staff recruitment files. Contact was also made during the inspection process with social care and mental health professionals associated with Colney Lodge. Information has also been drawn from the Annual Quality Assurance Assessment (AQAA) submitted last year by Colney Lodge to us (The Commission for Social Care Inspection - CSCI). This is a self-assessment that focuses on how well care outcomes are being met for people using the service and also includes some statistical information about the service. The proprietor confirmed that this year’s AQAA is currently being completed and that it will be sent to us within the required timescale. What the service does well: Colney Lodge provides effective care and support to people with complex mental health needs with a view, wherever possible, of helping people living there to achieve their personal goals and to gain the confidence and skills necessary to achieve a more independent lifestyle. The homely, domestic scale environment of Colney Lodge provides a comfortable and non-institutional setting in which the staff group, with their experience of working with people with a mental health problem, provide very individual and flexible care. “Our client has achieved some positive progress” was one comment made by a health/social care professional about the care outcome achieved for their client who lives in Colney Lodge. Colney Lodge DS0000060637.V362233.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Colney Lodge DS0000060637.V362233.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 Colney Lodge DS0000060637.V362233.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): 2 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service can be assured that where the pre-admission assessment process is fully applied, it is robust and thorough and should ensure that only those people whose needs can satisfactorily be met by the home are admitted. EVIDENCE: Care plans seen included evidence of a thorough and robust pre-admission assessment process that identified needs and how these were to be met. This should ensure that only those people who will benefit from a move to Colney Lodge are considered for admission. Although the assessment process for someone considering Colney Lodge as their home usually includes opportunities to visit the home and meet other people living or working there, this was not possible in the most recent case. This may have been a factor in the subsequent break-down of the placement as people already living in the home, staff and the prospective service user did not have sufficient time to make a fully informed judgement about whether the admission was likely to prove successful or not. Colney Lodge DS0000060637.V362233.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): 6 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service involves people living in it in the planning and detail of the care that affects them and supports them to make their own decisions and choices. This helps build independence and confidence on the part of the individual. EVIDENCE: A brief conversation with one of the people living in Colney Lodge provided confirmation that they are able to influence key areas of their care and to take appropriate risks. This was borne out by care plan and review records seen. It was confirmed by a health and social care professional involved with one person living in Colney Lodge that the person using the service had been able to increase their independent travel skills since moving into Colney Lodge. Care plans continue to be regularly reviewed under the Care programme Approach, this shows that the needs of those living in Colney Lodge are under Colney Lodge DS0000060637.V362233.R01.S.doc Version 5.2 Page 10 regular review and evaluation to ensure that their assessed needs are still being met. Colney Lodge DS0000060637.V362233.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): 12 13 15 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service can be confident that opportunities for personal development and appropriate activities are made available that meet their needs and expectations. EVIDENCE: People receiving care and support in this service are involved in meaningful daytime activities of their choice in line with their capabilities and interests and are fully involved in planning their care and support by means of long, medium and short-term goals that are kept under review. The person living in Colney Lodge spoken to during this inspection confirmed that they attend a variety of day care and are able to pursue interests outside of the home. Colney Lodge DS0000060637.V362233.R01.S.doc Version 5.2 Page 12 The majority of activities take place outside the home within the community, which provides opportunity for social interaction and contact. The person living in the home that it was not possible to speak to during this inspection was seen leaving the home to pursue activities in the community. Care plans for people living in the home include details of involvement with family and other interested parties, subject to the wishes of the individuals concerned. Records of multi-agency reviews seen and conversations held with health and social care professionals associated with people living in Colney Lodge provided positive evidence about the success Colney Lodge has in building confidence and increasing social contacts of those who receive care and support there. Meals are taken at times that suit the people living in the home. The AQAA submitted by the home indicates that menus are now being planned with people living in the home who are also encouraged to help with the necessary shopping. Discreet monitoring takes place to ensure a well-balanced, nutritious diet is achieved. Colney Lodge DS0000060637.V362233.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): 18 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The health needs of those receiving support and care in this service continue to be assessed, reviewed and met in ways that reflect their personal preference and in line with the advice and guidance of healthcare professionals involved with them. However, there are still occasions when the standard of medication practice and recording falls short of that required to provide people living in Colney Lodge with confidence that they are being given the support with their medication that they should be able to reasonably expect. EVIDENCE: Care plans seen include details of reviews and assessments made by a range of healthcare professionals, together with details of appointments made with specialist healthcare services to address specific healthcare needs that have arisen. Colney Lodge DS0000060637.V362233.R01.S.doc Version 5.2 Page 14 The comments of health and social care professionals associated with people living in Colney Lodge were again very positive about the standard of healthcare experienced by them. Medication records were checked and gaps were again found where administration had not been recorded. Totals of some medication checked did not agree with records and medication received was not always recorded. On at least one occasion medication was not available when required. These failures in medication practice could potentially adversely affect the health of those people living in Colney Lodge who rely on staff to support them with their medication. Failure to comply with the requirement may lead to enforcement action being taken. Colney Lodge DS0000060637.V362233.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): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in this service can be confident that their views will be actively sought and acted upon and that any concerns they have will be promptly and appropriately acted upon. People living in this service can be confident that they are protected by the training provided for staff that ensures the service’s safeguarding policies and procedures will be put into action where appropriate and necessary. EVIDENCE: Staff files seen provide evidence of recent training in safeguarding which should ensure that they are aware of how to identify any form of abuse and what to do if it is seen or suspected. The majority of staff also receive additional training in safeguarding through their employment within local mental health services. The person living in Colney Lodge spoken to indicated that they were satisfied with the way their views had been taken into account when problems arose recently that adversely affected them. People living in the home have ready and frequent access to individuals and services outside of the home, this provides ample opportunity for them to raise any concerns they may have independently. Colney Lodge DS0000060637.V362233.R01.S.doc Version 5.2 Page 16 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): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This service offers a homely and comfortable environment for those people who live and work there. EVIDENCE: Currently none of the people living in Colney Lodge require any adaptations or specialist equipment and the service meets their environmental needs adequately. One of the health and social care professionals associated with the home noted that the homely and domestic scale of the service was a positive factor in their assessment of the care received by their client. Although there were no obvious areas of concern seen in the brief tour of the premises undertaken during this visit it is expected that routine redecoration and refurbishment will continue in order to ensure that the standard of accommodation remains acceptable. Colney Lodge DS0000060637.V362233.R01.S.doc Version 5.2 Page 17 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): 32 34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living in Colney Lodge can be confident that the care and support they receive is provided by staff who have the necessary skills and experience to do so and who are supervised and supported through appropriate training provided for them. However, the standard of recruitment documentation does not always provide evidence of the necessary checks being done to fully protect people living in the home from the recruitment of unsuitable people to care for them. EVIDENCE: The file for the most recently recruited member of staff was seen. It did not include a suitable photograph, the application form was not fully completed, there was no health declaration and only one reference had been received at the time of the inspection. This means that the suitability of this member of staff could not be shown to have been robustly or effectively established prior to commencing employment, which could have posed a potential threat to the well being of people living in Colney Lodge. Colney Lodge DS0000060637.V362233.R01.S.doc Version 5.2 Page 18 Training records were seen and provided evidence that the staff team have the skills and training that they need to provide a good standard of care to people living in Colney Lodge. For example training in the safeguarding of vulnerable adults had been undertaken in June 2007 and again in February 2008. Most of the current staff team work part time at Colney Lodge and also within local mental health services. Staff files now include fuller details of the training that staff receive from all sources, as this is relevant in establishing their current competence and skills. Supervision records seen for a new member of staff showed that supervision had taken place in December 2007 and February 2008. However not all supervision records are clearly dated, doing so would provide more robust evidence that supervision is taking place at the prescribed intervals. All those individuals contacted during this inspection, including people living in the home and health and social care professionals associated with them were positive about the standard of care being provided by staff. Colney Lodge DS0000060637.V362233.R01.S.doc Version 5.2 Page 19 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): 37 39 41 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst the service is well run with good care outcomes being currently achieved for people living there, the persistent failure to maintain accurate medication records and failures found in basic recruitment practice leave people at potential risk of harm. EVIDENCE: There have been repeated failures found in medication records at each of the most recent inspections of this service which, given the limited number of entries, does not provide confidence that people living in the home are being adequately protected by the standard of medication administration recording. Colney Lodge DS0000060637.V362233.R01.S.doc Version 5.2 Page 20 The most recent recruitment file seen had some significant gaps, which does not demonstrate a suitably thorough, and robust recruitment process that fully protects people living in the home. The day- to- day management of the home remains, as it has for some time in the hands of the proprietor, who has not been registered as a fit person to manage a care service by the CSCI. Whilst it is readily acknowledged that the people living in the home and all health and social care professionals spoken to were very positive about and supportive of the way the home is being managed and the good care outcomes being achieved, the position of registered manager is a key one and should be filled as a matter of priority. The AQAA submitted by the home indicates that staff and service user meetings are held and that people living in the home, their families and health and social care professionals responsible for them are consulted and encouraged to contribute to decisions about how the service operates. Because of the scale of the service’s operation, much of this quality assurance is informal. Those health and social care professionals involved with the home stated that they were fully involved in decisions and are kept up to date by the proprietor in their regular visits to the service. Colney Lodge DS0000060637.V362233.R01.S.doc Version 5.2 Page 21 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 2 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 1 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 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 3 X 3 X 2 2 X Colney Lodge DS0000060637.V362233.R01.S.doc Version 5.2 Page 22 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 YA20 Regulation 13(2) Requirement Timescale for action 14/05/08 2. YA34 19(1)(b) & Schedule 2 To offer robust protection to those people relying on care staff to assist them with their medication any gaps in medication records must be identified at the earliest opportunity and appropriate action taken once the reason for the gap has been established and recorded. This requirement had a timescale of 30/05/07, which has not been met. Enforcement action is now being considered if compliance is not forthcoming. To protect people living in the 30/05/08 home from the recruitment of unsuitable people all the information required under schedule 2 of the Care Homes regulations 2001 must be obtained prior to employment including a recent photograph, two references and a declaration as to their health. Colney Lodge DS0000060637.V362233.R01.S.doc Version 5.2 Page 23 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 Colney Lodge DS0000060637.V362233.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Colney Lodge DS0000060637.V362233.R01.S.doc Version 5.2 Page 25 - 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!