Inspection on 30/05/07 for Colney Lodge

This inspection was carried out on 30th May 2007.

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 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 3 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 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 30th May 2007 10:00 Colney Lodge DS0000060637.V341732.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.V341732.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.V341732.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.V341732.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: There are none Date of last inspection 21st November 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 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 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 are £808. The individual service user pays for personal toiletries, newspapers and dental or chiropody charges if they apply. These charges were confirmed on 30/05/07. Colney Lodge DS0000060637.V341732.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection site visit took place during the course of one morning and provided an opportunity to speak to the one current person using the service along with the proprietor and one member of staff. It was also possible to look at some key records, including care plans, recruitment files and medication administration records. This inspection report also draws on information obtained from specialist social care professionals involved with this service and from the Annual Quality Assurance Assessment submitted by the service to the Commission for Social Care Inspection (CSCI). What the service does well: What has improved since the last inspection? The process for the registration of a manager has at last reached the stage where a determination is likely in the near future. Some changes have been made to the administration of medication to meet requirements previously made. Photographs of people using the service are now included within care plan documentation. Colney Lodge DS0000060637.V341732.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. The summary of this inspection report can be made available in other formats on request. Colney Lodge DS0000060637.V341732.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.V341732.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): 1234 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Existing people using the service are fully involved in the admission process to the home and care is taken to ensure the compatibility of any prospective resident with the person already resident and receiving care and support. EVIDENCE: Care plans include evidence of a thorough and robust assessment process, which should ensure that only those who will benefit from a move to Colney Lodge are considered. The admission process includes opportunities to visit the home, meet any existing residents and to stay overnight. This helps ensure that new and existing residents have an opportunity to meet one another and assess if they will be able to get on. Colney Lodge DS0000060637.V341732.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): 679 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service remains focussed upon providing care in a way that is responsive to the individual needs and aspirations of those living there. Individual goals and aims are established with the person concerned, involving all interested parties and those plans are monitored and amended as required. This ensures that those receiving care and support remain fully involved and at the centre of any decisions made that affect them. EVIDENCE: Individual care plan documents were examined and provided clear evidence of the involvement of the person concerned, with a good level of confirmatory signatures where appropriate. There is a clear risk assessment process in place that is focussed upon enabling people being supported in this service to become more independent. One example is by encouraging one person to make use of community services Colney Lodge DS0000060637.V341732.R01.S.doc Version 5.2 Page 10 such as hairdressers at a greater distance to the home in order to build confidence and familiarity with the use of public transport. Care plans have been regularly reviewed under the Care Programme Approach with good evidence that the needs of those using the service are constantly being reviewed and evaluated with them. Colney Lodge DS0000060637.V341732.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 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Those who receive care and support in this service continue to have short, medium and long term goals that are kept under review, with the aim of building their independence and confidence and enabling them to make increased use of educational, social and employment resources within the community as appropriate. EVIDENCE: One person using this service has increased his attendance at day centres and has made more independent journeys at greater distances. There is evidence in care plans of the involvement of families where that accords with the wishes of people receiving care and support in this service. Colney Lodge DS0000060637.V341732.R01.S.doc Version 5.2 Page 12 Multi-agency reviews and conversations with health and social care professionals both include positive comments about the way that this service works with them to reduce social isolation and build the confidence of the people receiving support and care in it. Very full daily records are kept, and these include details of meals taken. Colney Lodge DS0000060637.V341732.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 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 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 recording and practice continues to require further attention to reach a consistently acceptable standard although those using the service are generally adequately protected by the service’s policies and practice. EVIDENCE: Care plans contain details of reviews and assessments made by a range of health and social care professionals. The comments of people using this service and health and social care professionals responsible for them were very positive about the standard of personal and healthcare support provided. Medication records were checked. There was at least one gap in records and one error in carrying forward a total. Returns of medication no longer required Colney Lodge DS0000060637.V341732.R01.S.doc Version 5.2 Page 14 and changes in medication need to be properly recorded in order to protect the service and those receiving care and support from it. Colney Lodge DS0000060637.V341732.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 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The views of people using this service are actively sought and acted upon. This service has a comprehensive complaints and safe-guarding procedures in place which should provide those using this service that they are protected from abuse and that any concerns they may have will be listened to and taken seriously. The level of consultation that takes place is still not fully captured in formal records. EVIDENCE: Staff training is provided in safeguarding – further session is booked within the next few weeks of this inspection site visit. The majority of staff receive additional training in safeguarding through their employment within local health and social care services. The records of staff and service user meetings seen were infrequent and brief. Colney Lodge DS0000060637.V341732.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 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service continues to offer a homely environment for the people receiving accommodation, care and support within it. The premises are clean and hygienic and reasonably well maintained. EVIDENCE: Current and recent people living in this service have not required any specialist aids or adaptations to assist them in daily living. There were no obvious areas of concern seen during this visit. It is expected that routine maintenance and redecoration will continue to ensure that the standard of the accommodation remains acceptable. Colney Lodge DS0000060637.V341732.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 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staffing levels in the home remain adequate to meet the care needs of the person living there satisfactorily. Staff supervision and training is in place and recruitment checks are sufficiently thorough and robust to give those receiving care and support in the service confidence that they are receiving care from suitably recruited, supervised and trained staff. Staff training records do not yet fully meet the requirements of standard 35 and should be reviewed to demonstrate clearly the individual training and development profile for each staff member and for the staff team as a whole. These records should reflect the fact that as well as training received through Colney Lodge, staff receive training through relevant alternative employment in local mental health and social care services. EVIDENCE: The recruitment process for one new member of staff was seen and included the checks required to determine his suitability for the post. Training records were seen and staff members were consulted about the training they receive. Most staff members work part time at the home and work also within local health and social care settings. The training they receive Colney Lodge DS0000060637.V341732.R01.S.doc Version 5.2 Page 18 through Colney Lodge is therefore augmented by specific mental health qualifications and training received elsewhere. This is not always reflected in records. Further sessions of training in, for example, safeguarding vulnerable adults have been booked with an accredited training provider. People receiving support and care in this service spoken to during this inspection, together with the health and social care professionals spoken to who are responsible for them were all positive about the standard of care provided by staff. Colney Lodge DS0000060637.V341732.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 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. The proprietor remains significantly involved in the day-to-day operation of the service, although there is now an application in with the CSCI for the registration of a manager for this service. This post, in common with most within the service, is likely to be part-time. The scale of this service means that in practice much of the quality assurance is informal although some very brief records of resident’s meetings are kept. The outcomes for people receiving care and support from this service remain good. Colney Lodge DS0000060637.V341732.R01.S.doc Version 5.2 Page 20 EVIDENCE: The home does not currently have a registered manager in place. The work of the proprietor in managing the service was commented on very positively by the person receiving care and support and by the health and social care professionals involved with the service. Colney Lodge DS0000060637.V341732.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 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 3 35 2 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 2 X 2 X 3 X X 3 X Colney Lodge DS0000060637.V341732.R01.S.doc Version 5.2 Page 22 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13 (2) Requirement Records must be kept of the return of medication once it is surplus in order to provide a robust audit trail. Timescale for action 30/05/07 2. YA20 13(2) 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 is carried forward from the previous report and greater care must now be taken to ensure that it is met in full Changes in medication should wherever possible, be confirmed in writing by the person making the change. Individual records must fully record the details and circumstances of such changes. 30/05/07 3 YA20 13(2) 30/05/07 Colney Lodge DS0000060637.V341732.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 YA35 Good Practice Recommendations The proprietor should draw up a training and personal development profile for each member of staff and for the staff team as a whole. This should meet any requirements of the relevant training body such as Skills for Care and should address the need for staff to hold an appropriate NVQ qualification (or equivalent) Colney Lodge DS0000060637.V341732.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Hertfordshire Area 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.V341732.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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