Inspection on 24/01/06 for Dunheved Lodge

This inspection was carried out on 24th January 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Dunheved Lodge 22/10/07

Dunheved Lodge 26/02/07

Dunheved Lodge 15/08/05

Dunheved Lodge 17/02/05

Dunheved Lodge 25/06/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Dunheved Lodge 9 Dunheved Road North Thornton Heath Croydon Surrey CR7 6AH Lead Inspector Barry Khabbazi Unannounced Inspection 24th January 2006 9:30am Dunheved Lodge DS0000025779.V278948.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Dunheved Lodge DS0000025779.V278948.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Dunheved Lodge DS0000025779.V278948.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Dunheved Lodge Address 9 Dunheved Road North Thornton Heath Croydon Surrey CR7 6AH 020 8665 6405 020 8665 9034 NO EMAIL 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) Mr Cass Mohamedally Mrs Patricia Mohamedally Mr Eddy Muree Care Home 14 Category(ies) of Learning disability (14) registration, with number of places Dunheved Lodge DS0000025779.V278948.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th August 2005 Brief Description of the Service: Dunheved Lodge is a registered care home for 14 adults with mild to moderate learning disabilities and medium overall care needs. Dunheved Lodge is one of three similar homes owned by Mr and Mrs Mohammedally. The detached property is keeping with the other houses on the road. There are 11 single bedrooms and two doubles. There is a communal through lounge, a dining room and a kitchen. Other facilities include a laundry, staff sleeping in room and staff office. The home is located in Thornton Heath, within easy access of public transport and local shops. Residents of the home attend day centres on weekdays and the home has its own minibus and car. There is an established rear garden with areas of lawn, mature trees and bushes, a patio area and a barbeque. The front of the premises has a slope for access, and an in-out drive. Dunheved Lodge DS0000025779.V278948.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This home currently meets {and exceeds in some cases} all of the National Minimum Standards and has demonstrated many areas of good practice. Many of the areas of good practice identified refer to service user empowerment and involvement. These are priority areas for the Commission and also obviously for the service users. This view has been confirmed by the service user led inspection. See below. All of the Commission’s service user and relative surveys have also confirmed this view, with only positive comments about the home being received to date. Where shortfalls have previously been identified, these were of a minor nature and the manager has proven committed to fully meeting all areas and exceeding them where possible. The key Standards identified throughout this report were all assessed at the last inspection, which was the main inspection for the year. Please see that announced inspection report for a full audit of all the key Standards. In addition that inspection report also refers to a pilot undertaken, where the service users conducted a large part of the inspection themselves. It is hoped that a similar service user led inspection will occur at the next inspection. This un-announced inspection therefore focused on observing the morning routine for the service users, the implementation of recommendations in the recent fire officers report, and following up on previous good practice recommendations. Five of the residents were met during this inspection, most of whom were engaging in their independent living development programmes. None of the relative questionnaires received contained negative comments about care at the home. Specific positive comments included: My brother is very well cared for, I am more than satisfied with his care. Dunheaved Lodge is very well run. Our family have always been very happy with our brother’s care at Dunheaved Lodge, it must be one of the best in Croydon. Discussions with service users on this occasion concluded that they were happy at the home, liked the way they were treated and liked the food and holidays. Please see the last report referring to the service user led inspection for a comprehensive list of service users’ views at that time. Dunheved Lodge DS0000025779.V278948.R01.S.doc Version 5.1 Page 6 What the service does well: Evidence of Standards exceeded presented: Standard 8. ‘Opportunities to participate in the day to day running of the home and to contribute to the development and review of policies, procedures and services’. At the 2003 announced inspection, most service users independently chose to join in with the inspection and confidently took over the manager’s role in responding to the inspector’s questions regarding the Standards. The service users acted as if this level of involvement was expected from them and was their right. The service users also confidently initiated their involvement at following annual inspections. {See also Standard 38.} This home’s practice gave the inspector the idea for the service user inspection that occurred this year in this and the other two homes in the group. Standard 36 ‘Supervision frequency’, was evidenced as exceeded for the last three years, this ensures a well guided and appraised staff group. Standard 38-‘The manager creating an open and inclusive atmosphere’ was evidenced as exceeded. {see Standard 8.} Service user inclusion, involvement and service user consultation are areas of consistent good practice for this home, and the service users’ familiarity with involvement in the home, was one of the reasons that this home was selected for the service user inspection pilot recorded under the summary. This provides further evidence that Standard 8 – ‘service user consultation and participation in the running of the home’ and Standard 38 – ‘ethos of the home’, are exceeded. Evidence of good practice presented: Standard 2.3 only requires internal assessments for privately funded service users. Although the home does not have privately funded service users, it still produces an internal assessment for all its potential new admissions. This creates a higher level of knowledge of the needs of a new service user. Standard 6. The implementation of Person-Centred Planning for all service users will make them more central to the process of care provision. Standard 14, The home has contributed towards the cost of service users holidays from its own funds which facilitates more holidays. Standard 15. The home has promoted positive and appropriate relationships and protected service users from inappropriate relationships. Two service users are now married and share a room and their own lounge. Standard 33- This home benefits from a stable and long standing staff group which provide consistency of staff who know the service users well. Standard 40, Although the relevant accessible documentation standards have now been met, the home continues to build on the current achievements, and to continually explore and develop access to all relevant documentation on an ongoing basis. Dunheved Lodge DS0000025779.V278948.R01.S.doc Version 5.1 Page 7 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. Dunheved Lodge DS0000025779.V278948.R01.S.doc Version 5.1 Page 8 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 Dunheved Lodge DS0000025779.V278948.R01.S.doc Version 5.1 Page 9 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): These standards were all assessed as met at the last inspection and were not re-assessed at this follow-up inspection. Please see that inspection report for details. Details of previously identified good practice that are referred to elsewhere in this report are however included below. EVIDENCE: Evidence of good practice presented; Standard 2.3 only requires internal assessments for privately funded service users. Although the home does not have privately funded service users, it still produces an internal assessment for all its potential new admissions, including the most recent referral. This creates a higher level of knowledge of the needs of a new service user. Dunheved Lodge DS0000025779.V278948.R01.S.doc Version 5.1 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): These standards were all assessed as met at the last inspection and were not re-assessed at this follow-up inspection. Please see that inspection report for details. Details of previously identified good practice that are referred to elsewhere in this report are however included below. EVIDENCE: Evidence of good practice presented: Standard 6. Implementing Person-Centred Planning for all service users will make them more central to the process of care provision. Evidence of Standards exceeded presented: Standard 8. ‘Opportunities to participate in the day to day running of the home and to contribute to the development and review of policies, procedures and services’. At the 2003 announced inspection, most service users independently chose to join in with the inspection and confidently took over the manager’s role in responding to the inspector’s questions regarding the Standards. The service users acted as if this level of involvement was expected from them and was their right. The service users also confidently initiated their involvement at following annual inspections. {See also Standard 38.} This home’s practice gave the inspector the idea for the service user inspection that occurred earlier this year in this and the other two homes in the group. Dunheved Lodge DS0000025779.V278948.R01.S.doc Version 5.1 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): These standards were all assessed as met at the last inspection and were not re-assessed at this follow-up inspection. Please see that inspection report for details. Details of previously identified good practice that are referred to elsewhere in this report are however included below. EVIDENCE: Evidence of good practice presented: Standard 14. The home has contributed towards the cost of service users holidays from it’s own funds which facilitates more holidays. Standard 15. The home has promoted positive and appropriate relationships and protected service users from inappropriate relationships. Two service users are now married and share a room and their own lounge. Dunheved Lodge DS0000025779.V278948.R01.S.doc Version 5.1 Page 12 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): These standards were all assessed as met at the last inspection and were not re-assessed at this follow-up inspection. Please see that inspection report for details. EVIDENCE: Dunheved Lodge DS0000025779.V278948.R01.S.doc Version 5.1 Page 13 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): These standards were all assessed as met at the last inspection and were not re-assessed at this follow-up inspection. Please see that inspection report for details. EVIDENCE: Dunheved Lodge DS0000025779.V278948.R01.S.doc Version 5.1 Page 14 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): These standards were all assessed as met at the last inspection and were not re-assessed at this follow-up inspection. Please see that inspection report for details. EVIDENCE: Dunheved Lodge DS0000025779.V278948.R01.S.doc Version 5.1 Page 15 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): These standards were all assessed as met at the last inspection and were not re-assessed at this follow-up inspection. Please see that inspection report for details. Details of previously identified good practice that are referred to elsewhere in this report are however included below. EVIDENCE: Evidence of good practice presented: Standard 33- This home benefits from a stable and long standing staff group which provide consistency of staff who know the service users well. Evidence of Standards exceeded presented: Standard 36 ‘Supervision frequency’, was evidenced as exceeded for the last three years, this ensures a well guided and appraised staff group. Dunheved Lodge DS0000025779.V278948.R01.S.doc Version 5.1 Page 16 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): 42 The home promotes the health and safety of the residents, so that practices and the environment do not place their health and safety at risk EVIDENCE: Since the last inspection a Fire Officer has made a visit and recommended in that report for the home to record the testing of the emergency lighting. Records for this were seen at this inspection and a supporting requirement from the Commission is therefore not needed. Evidence of Standards exceeded presented; Standard 38-‘The manager creating an open and inclusive atmosphere’ was evidenced as exceeded. {See above, Standard 8 and see also the service user inspection pilot recorded in the summary.} Evidence of good practice presented; Standard 40, Although the relevant accessible documentation standards have now been met, the home intends to build on the current achievements, and to continually explore and develop access to all relevant documentation on an ongoing basis. Dunheved Lodge DS0000025779.V278948.R01.S.doc Version 5.1 Page 17 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 x 2 x 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 x 23 x ENVIRONMENT Standard No Score 24 x 25 x 26 x 27 x 28 x 29 x 30 x STAFFING Standard No Score 31 x 32 x 33 x 34 x 35 x 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score x x x x x LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 x 16 x 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x x x x x x x x x x x Dunheved Lodge DS0000025779.V278948.R01.S.doc Version 5.1 Page 18 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. Standard Regulation Requirement Timescale for action 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 YA14 Good Practice Recommendations The home must provide a minimum 7 day holiday to all service users, which is inclusive of care, funded by the placing authority, as a part of the contracted price. Dunheved Lodge DS0000025779.V278948.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Dunheved Lodge DS0000025779.V278948.R01.S.doc Version 5.1 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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