Inspection on 14/09/06 for Dover Lodge

This inspection was carried out on 14th September 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 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

Dover Lodge 31/10/05

Dover Lodge 15/07/05

Dover Lodge 23/11/04

Dover Lodge 27/05/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Townley Road, 2-3

Chatsworth Care - Tudor Lodge

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

CARE HOME ADULTS 18-65 Dover Lodge 41 Wood Vale London SE23 3DS Lead Inspector Lisa Wilde Unannounced Inspection 14 & 22 September 2006 2:00 th nd Dover Lodge DS0000060224.V312567.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 Dover Lodge DS0000060224.V312567.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. Dover Lodge DS0000060224.V312567.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dover Lodge Address 41 Wood Vale London SE23 3DS 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) 0208 693 5460 0208 863 8476 hazel@odysseycsft.org www.odyssey-csft.org Odyssey Care Solutions for Today Ms Hazel Joy Elkamouri Care Home 7 Category(ies) of Learning disability (7), Mental disorder, registration, with number excluding learning disability or dementia (2), of places Sensory impairment (1) Dover Lodge DS0000060224.V312567.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st October 2005 Brief Description of the Service: Dover Lodge is a large detached Victorian house situated in a residential road in Forest Hill. It is similar to other properties in the road and is not identifiable as a care home. This is one of a number of homes run by the voluntary organisation Odyssey. The home is not wheelchair accessible and does not have a lift. Up to 7 female service users with learning disabilities can live at the home. The ground floor has 2 sitting areas and a kitchen with dining area. The bedrooms and bathrooms are n the 1st and 2nd floors. There is a large well-maintained garden at the back. At the time of the inspection the home had no vacancies. Dover Lodge DS0000060224.V312567.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection visit took place over one day in September 2006. The inspector examined records and spoke with service users, staff and the Registered Manager. The inspector then spent a few days trying to telephone service users’ relatives but could not contact anyone before the draft report had to be written. The inspector found again that this is an excellent service. Service users said that they were very happy and that they liked staff. They liked their rooms and they liked the things they did during the week. The only requirements that were made were around medication handling and these issues were the same as at the last inspection. What the service does well: A lot of things at this home are good. • • • • • • • • • • • • Staff tell service users and their families about what goes on at the home. Someone new can only move to the home if staff know they will fit in. Someone new can only move to the home if staff know that they can help them. Staff find out what service users want and write this down for them. Staff write plans so they can help service users do what they want to do. Staff help service users make decisions. Staff listen to families and other people who know what service users want. Service users get to go out and do the things they want to do. Service users choose their own food and join in with cooking as much as they are can. Staff make sure service users go to the doctor when they need to. Staff protect service users from people who might hurt them. Service users have their own bedrooms. DS0000060224.V312567.R01.S.doc Version 5.2 Page 6 Dover Lodge • • • • • • • Service users can decorate their bedrooms how they want to. The home is clean and comfortable. Staff make sure the building is safe. Staff get good training. There are enough staff. The organisation checks out new staff before they start working at the home. Staff find out what service users and their families think and put in place plans to make things better. 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. Dover Lodge DS0000060224.V312567.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 Dover Lodge DS0000060224.V312567.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): 1&2 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users and their families are provided with all the information they need to make an informed choice about where to live and whether they are being offered everything that they should be. The needs and wishes of potential service users are fully assessed before someone is offered a place at the home. The staff team decide with the current service user group if they can meet the needs of someone who want to move in. EVIDENCE: There were prevous requirements that the Registered Manager must ensure that the Service User Guide is drawn up in a format that can be understood by more people from the service user groups for which the home is registered i.e learning disabilities and that the Registered Manager ensures that the Service User Guide covers all areas required by Regulation 5 and Standard 1. The Registered Manager has met with other managers in the organisation to discuss ways of changing the Service User Guide into other formats such as DVD and video and to ensure it is more meaningful for the service users. There is new legislation in place now that came into force on 01/09/06 and other changes come into force on 01/10/06 which will require services to state Dover Lodge DS0000060224.V312567.R01.S.doc Version 5.2 Page 9 exactly what fees each service user is paying and how it breaks down into different areas, in the service user guide. (See Recommendation 1) Most of the service users have been at this home for a long time and no service users have moved to the home since the last inspection. The Registered Manager discussed the process as it had occurred for the last person who moved to the home. A referral is received and the manager visits the applicant to assess their needs with them and their care team. The files showed that information is gathered prior to a decision being made as to whether the home can meet their needs. The current service users meet the prospective service users to assist with the decision as to whether they will fit in and if the home is suitable for them. Dover Lodge DS0000060224.V312567.R01.S.doc Version 5.2 Page 10 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 & 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Full assessments are made and guidelines drawn up to support service users with their care needs. Care plans are now in place to enable service users to meet identified goals or develop skills. Service users are given information to make decisions about their lives. Risks are assessed and plans put in place to manage or minimise those risks. Service users are supported to take reasonable risk as part of a normal lifestyle. EVIDENCE: The files showed that full assessments of need are`made and support guidelines are drawn up to meet the day–to-day needs`of service users. Annual reviews take place as required and goals are identified within those reveiws. There are nowcare plans in place that focus on development and moving forward. One example was that the Registered Managerhad described plans that were in place to assist with two service users who are having Dover Lodge DS0000060224.V312567.R01.S.doc Version 5.2 Page 11 difficulties with each other, yet nothing of this was written in care plans to allow staff action to be consistent and progress reviewed regularly.The Registered Manger dsicussed that she felt this was an area that was being looked at by the staff team currently and the recent training around Person Centred Planning has assisted with their thinking about this. The inspector discussed with the manager and staff the systems in place for enabling service users to make informed decisions and take reasonable risks. Risk assessments are on file with plans and guidelines to minimise or manage those risks. Families are involved as much as possible and independent advocates attend reviews and are involved in supporting service users to make complaints or voice concerns. Dover Lodge DS0000060224.V312567.R01.S.doc Version 5.2 Page 12 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 excellent. This judgement has been made using available evidence including a visit to this service. Service users are supported to undertake full weekly programmes that meet their leisure and educational needs. Service users have responsibility for their own lives in the home along with a responsibility to take part in activities that support the group living of the home such as cooking for the group. Service users individual rights are respected and the daily routines of the home do not impact negatively on those rights. Service users are supported to cook and eat a healthy, nutritious diet of their choice. Attention is paid to individual’s preferences and requirements. EVIDENCE: Service users have individual weekly plans that meet their leisure and educational needs. Dover Lodge DS0000060224.V312567.R01.S.doc Version 5.2 Page 13 Service users make their own choices around the lives they choose within the home. They are responsible for cleaning their own rooms with staff support and are as independent as possible given their varying support needs. Service users have recently been supported by staff and advocates to make complaints about how their day service has been withdrawn. One service user has recently been supported to find family they had lost touch with. Service users cook for the group one day each week with staff support as necessary. They choose what they will be cooking for that day. Service users make their own lunches with support and one service user said they liked the food at the home. Service users are supported with individual diets for example one service user doesn’t eat pork. The home is introducing picture records of foods and meals so there can be more useful choices made around food. The home is also focussing on how to ensure service user receive five portions of fruit or vegetables each day. Dover Lodge DS0000060224.V312567.R01.S.doc Version 5.2 Page 14 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 good. This judgement has been made using available evidence including a visit to this service. All service users’ personal, emotional and health needs are met by the staff team or by accessing community professional for specialist advice and input. The systems in place for the monitoring and recording of medication administration are not fully effective which means that the home is not keeping correct accounts of all medication held in the home. EVIDENCE: Discussions with staff and evidence from the files show that service users are fully supported to attend regular and ad hoc medical appointments. Staff showed a comprehensive knowledge of each service users individual needs. Service user at this home need low levels of support with personal care, requiring more support in the form of prompting and reminding to undertake tasks. One service user said they liked the staff and felt safe at the home. One family member said they had no problems with the way their relative was cared for at the home and when they did have day-to-day concerns they could approach staff and sort them out. The inspector checked the medication stocks and the administration records held at the home. There were some gaps in the recording of administration and Dover Lodge DS0000060224.V312567.R01.S.doc Version 5.2 Page 15 two of the medication stocks checked did not tally with the records. There were previous requirements in place around these two issues. (See Requirements 1 & 2) Staff receive training from the community pharmacist. Dover Lodge DS0000060224.V312567.R01.S.doc Version 5.2 Page 16 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’ comments and complaints are taken seriously and action is taken to address any concerns. The views of service users’ families are also listened to and acted on. The policy, procedures and training for staff mean that service users are protected from abuse by staff holding an understanding of what to look out for and what to do if any abuse is suspected. EVIDENCE: Formal and informal complaints and concerns are recorded, investigated and taken seriously. Recent complaints from staff about the withdrawal of funding for their day services have been copied to the Commission for information and showed that the home does all it can to make sure service users can voice their concerns and action is taken to attempt to resolve problems. The home has an appropriate policy around protection of vulnerable adults. Management and staff showed awareness of what to do and who to inform if they suspected abuse. Staff have recently received training in protection of vulnerable adults. Dover Lodge DS0000060224.V312567.R01.S.doc Version 5.2 Page 17 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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home and garden is bright, homely and clean throughout. The home is old and so some areas are in need of decoration but this has been planned in the annual budget. Service users have their own rooms and one service user has their own flat within the home all of which are large enough to meet the standards. Service users have chosen how their rooms are decorated. EVIDENCE: Bathroom and toilet numbers were sufficient and the whole house was homely and comfortable. Specialist aids and equipment are not necessary as the current service users do not have any mobility problems. The home is not wheelchair accessible. On the day of the inspection the home was clean and free from odours. Dover Lodge DS0000060224.V312567.R01.S.doc Version 5.2 Page 18 There was a previous requirement that the Registered Manager must ensure that the planned work on the kitchen takes place. This has now taken place. Certain areas of the home are in need of decoration particularly some service users’ rooms. The Registered Manager and Service Manager confirmed that this has been identified in the annual budget and will be done as planned by the end of the financial year. Dover Lodge DS0000060224.V312567.R01.S.doc Version 5.2 Page 19 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, 33, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff all hold or are undertaking the required NVQ in Care and this along with the additional training programme in place means that service users are offered support by a competent staff team. Service users are supported by an effective staff team in that there are enough staff on duty to support service users to undertake any activity they choose. The organisation makes sure that they do all the required checks and receive all the required documents before staff start working at the home. EVIDENCE: All staff hold or are undertaking the NVQ Level 3 in Care. Staff hold a full knowledge of service users needs and how they should work to meet them. There is a deputy manager in place who mostly works evenings and weekends which ensures there is some management support around at the home for most of the time. There was a previous requirement that the Registered Individuals must ensure that the current staffing review takes place as a priority and that evidence that the home is providing enough staff to meet all service users identified needs is Dover Lodge DS0000060224.V312567.R01.S.doc Version 5.2 Page 20 sent through to the Commission. This has been done and shows that the staffing levels are adequate to meet the needs of service users. The Registered Manager has completed the Commission’s checklists that show that all required recruitment information is held on all staff. The training records and comments from staff showed that a full training programme is in place which offers staff the core statutory training and additional specialist training around the specific needs of the service users. Dover Lodge DS0000060224.V312567.R01.S.doc Version 5.2 Page 21 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 excellent. This judgement has been made using available evidence including a visit to this service. The home does conduct reviews of individual service users care and incorporates those reviews into service development. The home ensures that service users views (or the views of their families) underpin the annual review and development of the home. Service users are protected by the operation of effective and robust systems for monitoring health and safety issues. EVIDENCE: The Registered Manager has been in post for several years and fully understands the needs of service users and how staff should work to meet those needs. She is currently undertaking the NVQ Level 4 Registered Managers Award and will then have to undertake the NVQ Level 4 in Care as she does not hold a nursing qualification. Dover Lodge DS0000060224.V312567.R01.S.doc Version 5.2 Page 22 The monthly visits required under Regulation 26 are carried out and sent through to the Commission. The home conducts annual reviews with the service users and completes quarterly returns to the borough organisation that report on identified indicators. There is a local business plan for the home. The home does not yet use an externally accredited quality assurance systems that focuses on the views of service users and the home does not conduct an annual review of the views of family and other stakeholders. The organisation has sent through plans to the Commission and these include how they plan to begin to use the PQASSO system of quality assurance before April 2007. Health and safety monitoring is regular and thorough. All the required documentation is in place. Dover Lodge DS0000060224.V312567.R01.S.doc Version 5.2 Page 23 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 4 2 3 3 X 4 X 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 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 4 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 4 X 3 X X 3 X Dover Lodge DS0000060224.V312567.R01.S.doc Version 5.2 Page 24 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 The Registered Manager must ensure that all medication is signed for at the point of administration. Previous requirement: Unmet timescale 30/11/05 The Registered Manager must ensure that systems for stock checking are effective and accurate records are maintained of all medication held in the home. Previous requirement: Unmet timescale 30/11/05 Timescale for action 14/09/06 2. YA20 13 (2) 14/09/06 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 YA1 Good Practice Recommendations The Registered Individuals should begin work on establishing exactly how each service users’ fees break down and put these in their service user guide. (This will become a legal requirement on 01/09/06 for current service users and 01/10/06 for new service users). Dover Lodge DS0000060224.V312567.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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 Dover Lodge DS0000060224.V312567.R01.S.doc Version 5.2 Page 26 - 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!