Inspection on 18/07/06 for Colney Lodge

This inspection was carried out on 18th July 2006.

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 5 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 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 Key Unannounced Inspection 18th July 2006 08:30 Colney Lodge DS0000060637.V304976.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.V304976.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.V304976.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) 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.V304976.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: There are none Date of last inspection 14th February 2006 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. 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 range from £769 to £808. The individual service user pays for personal toiletries, newspapers and dental or chiropody charges if they apply. These charges are current at July 2006. Colney Lodge DS0000060637.V304976.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection visit took place over the course of one morning and provided an opportunity to speak to service users, staff and the home’s proprietor. Sample records were examined and a visiting community health professional was able to give their opinion of the home and the standard of care provided. What the service does well: What has improved since the last inspection? The proprietor has met or is meeting all of the requirements and recommendations made following the previous, initial inspection of the service in February 2006. Administrative systems and records have been put in place to support and protect service users, for example in the process for recruitment and training of staff. Colney Lodge DS0000060637.V304976.R01.S.doc Version 5.2 Page 6 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. Colney Lodge DS0000060637.V304976.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.V304976.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12345 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users are fully involved in the admission process to the home and care is taken to ensure the compatibility of any new service user with those service users already living and receiving support in the home. The contract has been revised to include identification of the room to be occupied in the home. EVIDENCE: The admission process undertaken in respect of a recently admitted service user was examined and provided evidence of a robust and thorough series of assessments, visits and information gathering, involving service users, prospective service users, family and social and healthcare professionals. Contracts were seen to include a letter to identify the specific room to be occupied. The above all contribute to an effective and open process which has enabled the service to reach its registration capacity without detriment to the mental health and care of the existing or prospective service user. Colney Lodge DS0000060637.V304976.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 679 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The service is very focussed upon providing care in a way that is responsive to and fully involves the service user and their needs. Individual goals and aims are established with the service user, involving all interested parties, and these plans are monitored and amended as required. Care plan documentation does not yet include a photograph of the service user and this should be remedied. EVIDENCE: Individual care plan documentation was examined; this provided clear evidence of the involvement of the service user, with a good level of confirmatory signatures where appropriate. There are however no photographs of service users in the care plans. Developments in the lives of service users and their care are made within a clear risk assessment process, which is focussed on enabling rather than restricting an increase in independence. Colney Lodge DS0000060637.V304976.R01.S.doc Version 5.2 Page 10 Care plans have been reviewed under the Care Programme Approach and there is good evidence to show that service users’ needs are constantly being evaluated and reviewed with them. Colney Lodge DS0000060637.V304976.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 15 16 17 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Both service users have individual short, medium and longer-term goals that are constantly under review with them with the aim to increase social independence, gain confidence in accessing education and/or employment or other community resources. Meals taken are now recorded within each service user’s daily records. Colney Lodge DS0000060637.V304976.R01.S.doc Version 5.2 Page 12 EVIDENCE: One service user is in temporary employment, both service users are able to access the community and its resources and maintain social and family contacts where that is their wish. Progress by the home in assisting to reduce social isolation with one service user in particular is acknowledged in multi-agency reviews seen within care plan documentation. Daily records now contain details of meals provided as requested following the previous inspection in February. Colney Lodge DS0000060637.V304976.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 19 20 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Service users health and social care needs are assessed, reviewed and met in ways that reflect both their personal preferences and in line with the advice and guidance of the health and social care professionals involved with them. Medication procedures have been put in place to meet previous requirements made. Further requirements are made to improve the recording and monitoring of medication in the home. Colney Lodge DS0000060637.V304976.R01.S.doc Version 5.2 Page 14 EVIDENCE: Care plans contain details of reviews and assessments made by a range of health and social care professionals. Conversations with service users and records of comments made by them at reviews recently carried out were positive about the way that care is given. A community healthcare professional attended during this inspection to give a depot injection and a care manager (social worker) was due to call the next day to see one of the service users. Medication records were checked. There was at least one gap and the system of recording currently used does not permit the accurate reconciliation of medication amounts. Colney Lodge DS0000060637.V304976.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 23 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users’ views are actively sought and acted upon. The home has comprehensive complaint and protection of vulnerable adult procedures. As part of the ongoing development of this service more structured and “formalised” records of service user consultations could now be developed to reflect the extent of consultation that takes place. EVIDENCE: There have been no complaints about this service since the last inspection in February 2006. Training is provided in adult abuse and most of the staff receive training either through this employment or through employment within local health and social care services. Not all consultation that takes place is captured in formal records, and whilst it is not suggested that an over bureaucratic system is required, some method of demonstrating how and when service users views are canvassed and acted upon would be worth considering. Colney Lodge DS0000060637.V304976.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 30 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The home continues to offer a well maintained, comfortable and clean/hygienic environment for service users, which is essentially domestic in scale and layout. EVIDENCE: A brief “tour” of the premises was undertaken and there were no obvious areas of concern found. Work is planned to improve the rear conservatory and adjacent area, it is understood that this will take place this year. Neither of the current service users have any requirement for specialist aids or adaptations. Colney Lodge DS0000060637.V304976.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 34 35 36 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. The staffing levels in the home appear adequate to meet the care needs of the service users satisfactorily. Staff supervision and training is now in place and CRB records are being kept, which provide confidence that service users are appropriately supported and protected. One staff member had only provided one verifiable reference and the level of NVQ training has been recognised as not meeting the requirements of these standards. EVIDENCE: Service users expressed satisfaction with the quality of staff and were appreciative of the consistency of care received from a small staff team. Supervision records were seen and staff on duty confirmed that supervision takes place. Training records were seen and staff files include certificates of training undertaken. Colney Lodge DS0000060637.V304976.R01.S.doc Version 5.2 Page 18 A CRB log was seen and once the records had been authenticated, the inspector signed this. One recruitment file only included one confirmed written reference, although alternative referees had been asked to provide additional references. A fire drill was held in May, as part of a visit by the fire officer. The proprietor has booked places for staff on an NVQ course to address the shortfall in staff holding an appropriate NVQ level qualification. Colney Lodge DS0000060637.V304976.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 39 42 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. The service is well run, currently under the day-to- day supervision of the proprietor, during the absence of the registered manager. If the current registered manager chooses not to continue in that post, a replacement should be appointed and registered with the CSCI as a matter of priority. A more formal system of quality assurance should now be introduced in order to show how service users and other interested parties views of the service are sought and any information received used to develop and improve the service. Colney Lodge DS0000060637.V304976.R01.S.doc Version 5.2 Page 20 EVIDENCE: The proprietor has responded to any requirements and recommendations made following the home’s initial inspection and demonstrates a commitment to meet the National Minimum Standards that apply to this service. Service users, visiting community health professionals and records of reviews undertaken by social care professionals all provide positive evidence that this service is meeting the challenging needs of service users in a way that reflects their preferences and personal histories. The registered manager is not currently filling that role within the home. Colney Lodge DS0000060637.V304976.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 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 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 2 33 X 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 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 2 X 2 X 2 X X 3 X Colney Lodge DS0000060637.V304976.R01.S.doc Version 5.2 Page 22 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 YA6 Regulation 19, Sch 3 Requirement A photograph of each service user must be obtained for inclusion in the care plan documentation. Changes to the record of the administration of medication must be introduced to enable an accurate reconciliation of medication to be carried out at any time. 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. Two written references must be obtained for each member of staff. A suitable quality assurance process aimed at obtaining and recording the views of service users, families and carers and health and social care professionals associated with the home must be put in place. Timescale for action 31/08/06 2. YA20 13 (2) 18/07/06 3. YA20 13(2) 18/07/06 4. 5. YA34 YA39 17, Sch 2 24 31/07/06 31/10/06 Colney Lodge DS0000060637.V304976.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. 1 Refer to Standard YA22 Good Practice Recommendations The ways in which service users views and concerns, if any, are canvassed and acted upon, should be reviewed to see if they can be evidenced within a recording framework, without this becoming a disproportionate burden on the service. All care staff should be offered the opportunity to undertake NVQ training in care at level 2 or 3. The manager should undertake managerial training at NVQ level 4 or the Registered Managers Award as soon as a course becomes available. 3. 8. YA32 YA37 Colney Lodge DS0000060637.V304976.R01.S.doc Version 5.2 Page 24 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.V304976.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. 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