This inspection was carried out on 15th July 2005.
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 4 statutory requirements (actions the home must comply with) as a result of this inspection.
CARE HOME ADULTS 18-65
Dover Lodge 41 Wood Vale London SE23 3DS Lead Inspector
Lisa Wilde Unannounced 15 July 2005. 10:00AM
th 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 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 Stationary 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 G52-G02 S60224 Dover Lodge V238058 150705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Dover Lodge Address 41 Wood Vale, London, SE23 3DS Telephone number Fax number Email 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 Odyssey Care Solutions For Today Ms Hazel Joy Elkamouri CRH Care Home PC Care Home Only 7 Category(ies) of LD Learning Disability registration, with number MD Mental Disorder of places SI Sensory Impairment Dover Lodge G52-G02 S60224 Dover Lodge V238058 150705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 23rd November 2004 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 home. It is not wheelchair accessible and it does not contain a lift. It can accommodate a maximum of up to 7 female service users with learning disabilities. The accommodation is laid out over 4 floors. The ground floor contains 2 sitting areas and a kitchen with dining area. The bedrooms and bathrooms are located on the 1st and 2nd floors. There is a large wellmaintained garden at the rear with mature trees and shrubs. It is conveniently located for public transport and is close to the local park. At the time of the inspection the home had no vacancies. This is one of a number of homes run by the voluntary organisation Odyssey whos vision statement says that they are working towards A society where a learning disability is not a barrier to somebodys perceived value or ability to make a meaningful contribution.. Dover Lodge G52-G02 S60224 Dover Lodge V238058 150705 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place over one day in July 2005. The inspector spoke with the manager, staff and the four service users who were in the home at the time. The last inspection of this home had been announced and all the standards except two had been assessed and met. This inspection concentrated on speaking with service users to see if they were happy at the home and looking around the building to make sure the environment was safe and comfortable. What the service does well:
All four of the service users at the home on the day of the inspection said that they were very happy there. One woman has moved to the home since the last inspection and she said that she had no problems and felt very safe. Service users said that they liked the staff and they were kind. Service users are asked what they want on a day-to-day basis and given choices and information about the running of the home. Service users are supported to access individual and group activities as they choose. They are offered activities within the home and as part of the local community. Service users are supported to develop and maintain relationships within their families and with friends and partners. All service users have already been or are due to go on holiday this year. The home was bright and clean and there were no health and safety issues. Service users bedrooms enhance their independence as they are enabled to decorate their room as they choose and the toilets and bathrooms offered privacy and were in keeping with the homely atmosphere. There is decoration work planned for the kitchen but currently the kitchen environment is generally safe and free from hazard and still decorated and maintained to a comfortable standard. Generally service users are supported by an effective staff team in that there are usually enough staff on duty to support service users to undertake any activity they choose. On occasion this is not the case but it is not clear currently whether this is due to unforeseeable events or whether the rota’d staffing levels must increase. Service users benefit from a well run home. The manager is experienced and has the skills and awareness to ensure that the home can meet the service users’ changing needs. Dover Lodge G52-G02 S60224 Dover Lodge V238058 150705 Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Dover Lodge G52-G02 S60224 Dover Lodge V238058 150705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Dover Lodge G52-G02 S60224 Dover Lodge V238058 150705 Stage 4.doc Version 1.40 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 standard(s) 1 The Service User Guide is not in a language or form that could be understood by the service user group at this home and it does not include some of the areas required by the standard meaning that service users and their families are not 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. EVIDENCE: Odyssey have the same Service User Guide and Statement of Purpose for all their homes. This home is registered for learning disabilities and it is possible to draw up a service user guide in a language and format that could be understood by people from those groups who may wish to use this home e.g. by using pictures, video and language that is more simple. (See Requirement 1) The Service User Guide does not cover the required areas of the numbers of places provided; the relevant qualifications and experience of the staff; key contract issues of occupancy and termination; fees charged, what they cover and fees for any ‘extras’; service users’ (or their families’) views of the home and a copy of the complaints procedure and information about how to contact the local CSCI office and local health and social services. (See Requirement 2) Dover Lodge G52-G02 S60224 Dover Lodge V238058 150705 Stage 4.doc Version 1.40 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 standard(s) 8 Service users are asked what they want on a day-to-day basis and given choices and information about the running of the home. EVIDENCE: There are service user meetings which the manager said they are trying to formalise more now with them being service user led rather than staff led. All staff have recently had training in Person Centred planning and they talked about how they aim to meet each service users needs as they describe them bearing in mind issues such as budgets or other practicalities. Service users said that staff talk to them and ask them what they want all the time and that they can chose what they do, what they eat and how they live. Families are involved to varying levels but the manager said that they do not make a point of consulting formally with the service users families. (See Recommendation 1) Dover Lodge G52-G02 S60224 Dover Lodge V238058 150705 Stage 4.doc Version 1.40 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 standard(s) 12, 13, 14 & 15 Service users are supported to access individual and group activities as they choose. They are offered activities within the home and as part of the local community. Service users are supported to develop and maintain relationships within their families and with friends and partners. EVIDENCE: All service users have been or are due to go on holiday this year. All service users attend one of the local day centres and then undertake different activities as they choose. One service user has a boyfriend and most have family who they visit. The inspector spoke with service users and staff and saw the records of activities on the weekly planner. Dover Lodge G52-G02 S60224 Dover Lodge V238058 150705 Stage 4.doc Version 1.40 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 standard(s) X All these standards were assessed as met at the last inspection. EVIDENCE: Dover Lodge G52-G02 S60224 Dover Lodge V238058 150705 Stage 4.doc Version 1.40 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 standard(s) X These standards were assessed as met at the last inspection. EVIDENCE: Dover Lodge G52-G02 S60224 Dover Lodge V238058 150705 Stage 4.doc Version 1.40 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 standard(s) 24, 25, 26, 27 28, 29 and 30 All the outcomes for these standards were met. The home was bright and clean and there were no health and safety issues. Service users bedrooms enhance their independence as they are enabled to decorate their room as they choose and the toilets and bathrooms offered privacy and were in keeping with the homely atmosphere. There is decoration work planned for the kitchen but currently the kitchen environment is generally safe and free from hazard and still decorated and maintained to a comfortable standard. EVIDENCE: The home was clean and free from odours. Service users’ bedrooms were decorated to individual tastes with the required furniture and fittings. Bathroom and toilet numbers were sufficient and the whole house was homely and comfortable. The planned kitchen work has still not been undertaken and the manager said that they were not as yet certain whether this work would be done in this or the next financial year. (See Requirement 3) Specialist aids and equipment are not necessary as the current service users do not have any mobility problems. The home is not wheelchair accessible. Dover Lodge G52-G02 S60224 Dover Lodge V238058 150705 Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 Generally service users are supported by an effective staff team in that there are usually enough staff on duty to support service users to undertake any activity they choose. On occasion this is not the case but it is not clear currently whether this is due to unforeseeable events or whether the rota’d staffing levels must increase. EVIDENCE: Staff reported that with the current rota it is one occasion not possible to allow the service users to do all the activities that they have chosen. The manager acknowledged that the rota is a little tight but that she felt it was appropriate given the number of service users they have had up to this point and that they have been carrying a deputy manager vacancy. The manager is currently reviewing the staffing levels with senior managers (See Requirement 4) Discussions with staff showed that they held a thorough knowledge of the individual service users’ needs. Dover Lodge G52-G02 S60224 Dover Lodge V238058 150705 Stage 4.doc Version 1.40 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 Service users benefit from a well run home. The manager is experienced and has the skills and awareness to ensure that the home can meet the service users’ changing needs. EVIDENCE: The manager showed a thorough awareness of service users needs, how staff should meet those needs and an ability to manage the care home throughout the inspection. She is currently studying for the NVQ Registered Manager’s Award Level. Dover Lodge G52-G02 S60224 Dover Lodge V238058 150705 Stage 4.doc Version 1.40 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 x x x x Standard No 22 23
ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score x x 3 x x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 2 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 3 x x Standard No 31 32 33 34 35 36 Score x x 2 x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Dover Lodge Score x x x x Standard No 37 38 39 40 41 42 43 Score 3 x x x x x x G52-G02 S60224 Dover Lodge V238058 150705 Stage 4.doc Version 1.40 Page 17 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 YA1 Regulation 5 Requirement The Registered Manager must ensure that the Service User Guide must be 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. The Registered Manager must ensure that the Service User Guide must cover all areas required by Regulation 5 and Standard 1. The Registered Manager must ensure that the planned work on the kitchen takes place. Unmet requirement (but reworded in this report); Previous timescale 30/01/05 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 sent through to the Commission. Timescale for action 31/12/05 2. YA1 5 31/12/05 3. YA24 23 (2) (d) 30/11/05 4. YA33 18 (1) (a) 31/10/05 Dover Lodge G52-G02 S60224 Dover Lodge V238058 150705 Stage 4.doc Version 1.40 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. Refer to Standard YA8 Good Practice Recommendations The Registered Manager should consider consulting formally with service users families and other stakeholders (in addition to service users) as to their views of the service provided by the home. Dover Lodge G52-G02 S60224 Dover Lodge V238058 150705 Stage 4.doc Version 1.40 Page 19 Commission for Social Care Inspection 46 Loman Street Southwark London SE1 0EH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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