CARE HOME ADULTS 18-65
Enmore Lodge 34-36 Enmore Road South Norwood London SE25 5NQ Lead Inspector
Mohammad Peerbux Unannounced Inspection 28th November 2005 9:30 Enmore Lodge DS0000025780.V267771.R01.S.doc Version 5.0 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 Enmore Lodge DS0000025780.V267771.R01.S.doc Version 5.0 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. Enmore Lodge DS0000025780.V267771.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Enmore Lodge Address 34-36 Enmore Road South Norwood London SE25 5NQ 020 8405 1831 020 8656 9792 enmorelodge@msn.com 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) Enmore Lodge Limited Care Home 16 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (16) of places Enmore Lodge DS0000025780.V267771.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. A variation has been granted to allow two specified service users over the age of 65 to be accommodated. 9th June 2005 Date of last inspection Brief Description of the Service: Enmore Lodge is a service designed to cater for sixteen generally younger adults with past / present mental illness. Using a long-term therapeutic model, service users are encouraged to engage in the day-to-day activities of the home, as well as become involved with the local community where wished, or where timetabled as part of their care programme. Enmore Lodge is a substantial building set back off Enmore Road with a large car park to the front and a paved patio area to the rear with a small plot of garden. The building is designed to provide single accommodation for all but two of the service users who share the sole double-occupancy room. Enmore Lodge DS0000025780.V267771.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the home’s second inspection for the year 2005/06. It was an unannounced inspection and took place over three hours. Some times were spent looking at the records and talking to the manager, staff and service users. A tour of the building was also carried out. Requirements and recommendations from the previous inspection were also discussed with the manager. They are all thanked for their time and assistance. Two immediate requirements were issued during this inspection. One was in regard to the hot water temperature being above the recommended level and the other was regarding the Control of Substances Hazardous to Health cupboard being left unlocked. A follow up visit was carried out after the initial inspection and it was noted that the registered manager has taken steps to address these issues. What the service does well: What has improved since the last inspection?
A copy of the latest inspection report is now included in the Service User’s Guide and all staff working in the home have a job description in place so that they are aware of their roles and responsibilities. Care staff are receiving supervision on a regular basis, which contributes to the standards of care being provided to service users. Enmore Lodge DS0000025780.V267771.R01.S.doc Version 5.0 Page 6 The home has developed service user’s medication profiles with the service user’s photographs on them. This will help new staff to identify the service users more easily. 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. Enmore Lodge DS0000025780.V267771.R01.S.doc Version 5.0 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 Enmore Lodge DS0000025780.V267771.R01.S.doc Version 5.0 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 The Statement of Purpose, and Service User Guide provide prospective service users with details of the services the home offers. This enables them to make an informed decision about admission to the home. EVIDENCE: The home has a Statement of Purpose that complies with the minimum standards. This is very comprehensive and was last reviewed in December 2004. The Service User’s Guide is written in a format/language suitable for the service users. It was previously required that a copy of the last inspection report is included in the Service User’s Guide. This is now in place. Enmore Lodge DS0000025780.V267771.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 and 10 Service users are involved in decision making about their lives, they participate and can take some risks so that they live as normal a life as possible. The home has a confidentiality policy in place, which ensure information is handled in the best interests of the service users. EVIDENCE: The rights of service users to make decisions about their own lives is central to the ethos of the home, support and guidance is given in all areas to ensure that service users are making decisions which are in their best interests. The home supports most of the service users to look after their own money. Service users receive personal allowances on a daily basis or as and when needed. It was previously required that the manager must ensure that accurate records are kept as far as service users’ monies are concerned. During this inspection it was noted that all transactions were duly recorded, however there were no receipts for these transactions. The manager is required to keep an up to date records and receipts of all the expenses made by the service users or on their behalf by staff. Enmore Lodge DS0000025780.V267771.R01.S.doc Version 5.0 Page 10 The home has a confidentiality policy in respect of personal information held in relation to service users. General service user’s documentations (i.e. service user plan, medical appointments and reviews) are kept locked in the office. Staff respect information given by service users in confidence. The home also has guidance on the Data Protection Act. Enmore Lodge DS0000025780.V267771.R01.S.doc Version 5.0 Page 11 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 Service users are encouraged to explore opportunities to enhance their quality of life. EVIDENCE: The home encourages all its service users to maintain their life skills and participate in activities appropriate to their abilities. Where appropriate, service users are encouraged to attend basic literacy and numeracy classes and staff support service users to access local facilities including computer training at local colleges. The home also offers in-house activities, Enmore Lodge DS0000025780.V267771.R01.S.doc Version 5.0 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): 20 and 21 The systems for administration of medication are poor and potentially place service users at risk. EVIDENCE: The medication administration records were audited. There were several instances where prescribed medication had been omitted or administered but not signed for. While it transpired that there were acceptable explanations for this, these explanations had not been recorded. In all cases where medication is not given as prescribed, staff must ensure that they record the reason for this. The manager must ensure that medication administration records are accurately completed at all times. It was previously recommended that that the manager develop a service user’s medication profile with their photographs on them. This will help new staff to identify the service users more easily. These are now in place. The manager stated that all the homes service users and their respective families have been consulted about their wishes concerning terminal care and death, including religious and cultural customs to be observed, in the event of a service user’s death. Written acknowledgment of these discussions has been placed on each service users files. Enmore Lodge DS0000025780.V267771.R01.S.doc Version 5.0 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): 22 Complaints are generally managed well, which should ensure that service users’ and relatives’ concerns are listened to. EVIDENCE: The complaints procedure and book were seen. The complaints procedure was clear and contained all of the elements required to meet Standard 22 including a minimum response time of less than 28 days. The Commission received an anonymous letter regarding two issues of concern regarding the home. The issues were staff turnover and qualifications and service users not receiving their personal allowances although they are signing for them on a daily basis. These issues were investigated and discussed with the registered manager during the course of this inspection. Enmore Lodge DS0000025780.V267771.R01.S.doc Version 5.0 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): EVIDENCE: None of the above standards were assessed during this inspection. Enmore Lodge DS0000025780.V267771.R01.S.doc Version 5.0 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): 31,34 and 36 The staff team at the home have a range of skills and ability, which appear to meet the needs of the service users. Care staff are receiving supervision on a regular basis, which contributes to the standards of care being provided to service users. EVIDENCE: Staff job descriptions are available for support and senior support workers which are clearly linked to achieving service users’ individual goals as set out in care plans and refer to individual service users needs in relation to their personal, social and health care. The job descriptions also contain the main purpose, tasks, including household and administrative tasks staff is expected to perform and be responsible for. This is in line with the requirement made at the last inspection. As part of the inspection process staff files were sampled at random and found to contain photographs, application forms, references, criminal record checks, application forms and copies of identification. It was previously required that the manager must ensure that supervision records are available at all times in the home for inspection and that all staff receive regular supervision. The registered provider advised that all the homes care staff receive at least six supervisions a year covering good care practices
Enmore Lodge DS0000025780.V267771.R01.S.doc Version 5.0 Page 16 and career development. From staff files sampled at random there were evidence that staff are being supervised on a regular basis. Enmore Lodge DS0000025780.V267771.R01.S.doc Version 5.0 Page 17 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 is generally managed well however the health, safety and welfare of service users and staff are not being promoted/protected and this potentially places them at risk. EVIDENCE: It was previously required that the manager must ensure that all hazardous materials are kept locked in accordance with Control of Substances Hazardous to Health Regulations.However it was noted that the cupboard was left unlocked again during this inspection. An immediate requirement was issued to that effect. Failure to comply with the aforementioned requirement represents serious breaches of the Regulations and urgent action must be taken by the registered persons to address this to avoid the Commission taking further action to enforce compliance. During the inspection it was also noted that the hot water temperature in the two bathrooms were above the recommended level of 43 degrees. An Enmore Lodge DS0000025780.V267771.R01.S.doc Version 5.0 Page 18 immediate requirement was issued to address this issue. A follow up visit was carried out and both immediate requirements have been addressed. Enmore Lodge DS0000025780.V267771.R01.S.doc Version 5.0 Page 19 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 3 X X X X Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X 2 X X 3 Standard No 24 25 26 27 28 29 30
STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score 3 X X 3 X 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Enmore Lodge Score X X 2 3 Standard No 37 38 39 40 41 42 43 Score X X X X X 1 X DS0000025780.V267771.R01.S.doc Version 5.0 Page 20 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 YA7 Regulation 17(2) Requirement The manager is required to keep an up to date records and receipts of all the expenses made by the service users or on their behalf by staff. Timescale for action 31/01/06 2. YA20 13(2) The manager must ensure that 31/01/06 medication administration records are accurately completed at all times. The Registered Provider must ensure that the hot water temperature is always within recommended level. The manager must ensure that all hazardous materials are kept locked in accordance with Control of Substances Hazardous to Health Regulations. 29/11/05 3. YA42 13(4) 4. YA42 13(4) 28/11/05 Enmore Lodge DS0000025780.V267771.R01.S.doc Version 5.0 Page 21 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Enmore Lodge DS0000025780.V267771.R01.S.doc Version 5.0 Page 22 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
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