Inspection on 14/02/06 for Colney Lodge

This inspection was carried out on 14th February 2006.

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 found no outstanding requirements from the previous inspection report, but made 6 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 14/04/08

Colney Lodge 30/05/07

Colney Lodge 18/07/06

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 Mr Robert Kittle Unannounced Inspection 14th February 2006 10:00 Colney Lodge DS0000060637.V277901.R01.S.doc Version 5.1 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.V277901.R01.S.doc Version 5.1 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.V277901.R01.S.doc Version 5.1 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) Colney Lodge Limited Ebenezer Lovelace Lartey Care Home 2 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (2) of places Colney Lodge DS0000060637.V277901.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th December 2005 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 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 is located relatively close by. Colney Lodge DS0000060637.V277901.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. When the home was last inspected, the first service user had not been admitted to the home and this, therefore, should be considered to be the first definitive inspection of Colney Lodge. Two inspectors undertook this initial visit and the service user (who was admitted on 20 January 2006), the proprietor and care worker were at the home. As is commonly found following a first inspection after a home has begun operation, the report contains a number of requirements and recommendations, although the most important points to be borne in mind is that the service is appropriate to the needs of the service user and is safe. This was therefore a positive first inspection. What the service does well: What has improved since the last inspection? What they could do better: Attention needs to be paid to record keeping generally. If effective and comprehensive systems are begun now, they will stand the home in good stead in the future. There are recommendations and requirements made in this report about training and this too is an area that, if properly set up now, will be of considerable benefit for the foreseeable future. Medication administration practice must be improved and additional professional support for staff should be introduced. Colney Lodge DS0000060637.V277901.R01.S.doc Version 5.1 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. Colney Lodge DS0000060637.V277901.R01.S.doc Version 5.1 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.V277901.R01.S.doc Version 5.1 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, 2, 3, 4 and 5 Prospective service users are fully involved with the admission process to this home and copies of the statement of purpose and service user’s guide are provided on admission. EVIDENCE: The admission process appears to have been thorough and at a pace suited to the service user. The management obtained a profile of the prospective service user from the placing authority to ensure that the identified needs could be met. They next visited the prospective service user who then undertook a visit to the home, accompanied by his social worker. Working closely with the multidisciplinary team, there was a gradual familiarisation with the home undertaken, including a day visit and an overnight stay. Following admission, the process of establishing a rapport and introducing gradual changes to improve the service user’s lifestyle has begun. The service user told the inspector that he was happy with his placement to date and made positive comments about the manager and proprietor. It was recommended that the contract be amended slightly to ensure that it meets the national minimum standards (e.g. include service user’s room number). Colney Lodge DS0000060637.V277901.R01.S.doc Version 5.1 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, 7, 8, 9 and 10 Although the home has only had a service user in residence for a month, it is evident that he is as involved as he wishes in making choices and that the life in the home is currently completely focussed on his wellbeing. EVIDENCE: The service user is involved in his care planning and had signed the review contained in his care plan. Both the service user and the staff that support him are exploring avenues that will lead to him following a more independent lifestyle. There is an immediate need to establish a proper eating pattern and a need to gradually introduce the concept of outings as a pleasurable experience. Colney Lodge DS0000060637.V277901.R01.S.doc Version 5.1 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 the following standard(s): 11, 12, 13, 14, 15, 16 and 17 The service user is not ready to embrace an independent lifestyle at present and this is respected. However, he is being offered opportunities and choices that could lead to an improved quality of life. EVIDENCE: Choices surrounding lifestyles are an evolving situation for the service user at present. The service user is not used to engaging with the community and staff are gently working with him in an effort to persuade him to adjust his mindset. The daily notes reflect this. His family are very supportive, but currently he resists visits. He says when he will receive visitors and this is respected. The service user reads and occasionally watches television. He confirmed that he enjoyed the food provided although he also said that, “They surprise me sometimes” when asked if he always knows what to expect. Staff will begin to record meals served on the daily notes. Colney Lodge DS0000060637.V277901.R01.S.doc Version 5.1 Page 11 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): 18, 19, and 20. A person-centred service is being provided for the service user with his physical and emotional needs dictating the pace of life at the home. EVIDENCE: It appeared through observation, conversation and available records that all personal and healthcare support being provided was entirely appropriate for the service user and in accordance with his wishes. The care plan included details of how support is to be given and the service user had signed the document. Currently the service user copes with some of his medication and staff will work with him to extend this over time. There is room for improvement in the recording of medication administered by staff, and the introduction of medication administration recording sheets (MAR) will resolve most of the issues. In addition, there is a need to date prescribed medication containers on opening to enable reconciliation. Ideally, the supplying pharmacist should dispense straight into a dosette box to prevent double dispensing. Colney Lodge DS0000060637.V277901.R01.S.doc Version 5.1 Page 12 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 service user views are actively sought and acted upon. The home has comprehensive complaint and protection of vulnerable adult procedures. EVIDENCE: There have been no complaints about this service. The staff member on duty was fully conversant with the complaint procedure and the County Council’s vulnerable adults process (with which the home co-operates). The staff member was also able to demonstrate a working knowledge of the whistleblowing process. In view of the forgoing comments on how the service user is consulted, it is reasonable to conclude that these standards have been fully met. Colney Lodge DS0000060637.V277901.R01.S.doc Version 5.1 Page 13 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, 26, 27, 28 and 29. The home, which met the requirements of the Care Homes Regulations when it was registered in June 2005, was maintained to a good standard of cleanliness. EVIDENCE: As can be expected from a home that has only been operational for about a month, the environment was both clean and safe. The service user was satisfied with the facilities and has no need of specialised equipment. Colney Lodge DS0000060637.V277901.R01.S.doc Version 5.1 Page 14 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): 31, 32, 33, 34, 35 and 36 Staffing arrangements appeared to be satisfactory and the service user was positive about the support and care he was receiving. EVIDENCE: The manager, a part-time registered nurse and two support workers as well as the proprietor provide care in this home. The manager as not on duty when this inspection took place, although the care worker that was on duty appeared to be knowledgeable and experienced. It was not possible to make a judgement about the thoroughness of the recruitment processes, as not all required records were available (three files only included references). However, information that was included in the staff files indicated that staff members had appropriate professional backgrounds and had received relevant training to date. It is planned to introduce a programme of formal supervision sessions soon. Ideally, the management will prepare a training programme for the coming year. This must include a fire drill as a matter of priority. Copies of the General Social Care Council’s codes of practice should be obtained and provided for each member of staff. Colney Lodge DS0000060637.V277901.R01.S.doc Version 5.1 Page 15 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, 38, 39, 40, 41, 42 and 43 This new service is being run in a manner that is suited to meeting the needs of the service user. EVIDENCE: Overall, the home is focussed on providing the maximum support and benefit to the service user. Although the report contains a number of requirements and recommendations, this is not considered to be unusual considering that the home did not become operational until some six months after it was registered. The acid test will be the number made at the next inspection. One member of staff is undertaking an NVQ at level 2 and the manager will be undertaking his RMA award as soon as a course becomes available. A suggestion was made that a CRB register be created. There is a need to take and record refrigerator and freezer temperature to ensure the safe storage of food and all food in the refrigerator must be covered and the container dated. Colney Lodge DS0000060637.V277901.R01.S.doc Version 5.1 Page 16 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 3 2 3 3 3 4 3 5 2 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 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 2 33 3 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 3 3 3 3 2 3 Colney Lodge DS0000060637.V277901.R01.S.doc Version 5.1 Page 17 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 2 3 4 5 6 Standard YA17 YA20 YA20 YA34 YA36 YA42 Regulation 17 (2) Sch. 2.13 13 (2) 13 (2) 17 (2) Sch. 4.6 23 (4) (c) (iii) 16 (2) (g) Requirement A record of meals served must be kept. A record of all aspects of the administration of medication must be introduced. Prescribed medication containers must be dated when opened to enable reconciliation. All required staff records must be available for inspection. A fire drill must be undertaken and repeated at appropriate intervals throughout the year. Refrigerator and freezer temperatures must be taken and recorded daily to ensure the safe storage of food and all frozen food must be covered and dated. Timescale for action 01/03/06 01/03/06 01/03/06 01/03/06 31/05/06 01/03/06 Colney Lodge DS0000060637.V277901.R01.S.doc Version 5.1 Page 18 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 4 5 Refer to Standard YA5 YA17 YA32 YA34 YA34 Good Practice Recommendations The contract needs to be amended slightly to ensure that it meets the national minimum standards (e.g. include service user’s room number). It is recommended that the record of meals served be kept on the service users daily notes. All care staff should be offered the opportunity to undertake NVQ training in care at level 2 or 3. It is recommended that each staff member be provided with a copy of the GSCC code of practice. It was suggested that a CRB disclosure register be introduced, containing the unique disclosure number and the individual’s name, date of birth and postcode. The Commission’s inspector could then sign this register before the original documents were destroyed. It is recommended that the practice of providing staff with regular supervision (at least six times a year) be introduced without further delay. A programme of training for the forthcoming year should be drawn up. The manager should undertake managerial training at NVQ level 4 or the Registered Managers Award as soon as a course becomes available. 5 6 7 YA36 YA36 YA37 Colney Lodge DS0000060637.V277901.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ 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 Colney Lodge DS0000060637.V277901.R01.S.doc Version 5.1 Page 20 - 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!