Inspection on 07/08/07 for Enmore Lodge

This inspection was carried out on 7th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 no outstanding requirements from the previous inspection report, but made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Enmore Lodge 10/04/06

Enmore Lodge 28/11/05

Enmore Lodge 09/06/05

Enmore Lodge 13/01/05

Enmore Lodge 01/06/04

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Tudor Lodge

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Delrose House Ltd

Clovelly House Residential Home Ltd

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Cherry Tree House

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

CARE HOME ADULTS 18-65 Enmore Lodge 34-36 Enmore Road South Norwood London SE25 5NQ Lead Inspector Mohammad Peerbux Key Unannounced Inspection 7 and 28th August 2007 9:30am th Enmore Lodge DS0000025780.V342437.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 Enmore Lodge DS0000025780.V342437.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. Enmore Lodge DS0000025780.V342437.R01.S.doc Version 5.2 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 Post Vacant Care Home 16 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (16) of places Enmore Lodge DS0000025780.V342437.R01.S.doc Version 5.2 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. 10th April 2006 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. The range of weekly fees is between £550 and £850. Enmore Lodge DS0000025780.V342437.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit to the home was undertaken as a part of the inspection process for the year 2007/2008. It took place over two days as the Registered Manager was on leave abroad. In writing the report consideration has also been given to information received throughout the year such as comments from people who use the service, reports of incidents and complaints. Some times were spent looking at the policies and procedures, records, talking to the residents, and staff. They are all thanked for their time and all of those who provided feedback for their support in the inspection process. A tour of the building was also carried out. What the service does well: What has improved since the last inspection? It was previously required that all emergency fire exit doors are openable without the use of a key whenever the premises are occupied. This is now in place. Enmore Lodge DS0000025780.V342437.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Enmore Lodge DS0000025780.V342437.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 Enmore Lodge DS0000025780.V342437.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has its own assessment plan to ensure that any new resident’s needs are fully assessed prior to their admission and that staff are aware of how to support them. EVIDENCE: The home consults the assessment information to see if they can meet the prospective individual’s needs before they make the decision to accept the application for admission and offer a placement. Evidence suggests that prospective people who use services have a needs assessment carried out before they are admitted to the home. The home has received copies of the summary, and care plans, from those assessments carried out through care management arrangements for most of the residents. The assessments are generally undertaken satisfactorily. Areas around equality and diversity are also taken in consideration. Enmore Lodge DS0000025780.V342437.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Generally residents’ care plans include detailed information about their needs and personal goals. This helps staff to know the residents’ needs and how to meet them. EVIDENCE: Each individual has a care plan, which includes basic information necessary to deliver the resident’s care but is not detailed or person centred. The home must ensure that care plans cover all aspects of personal and social support and healthcare needs of the residents. The plan must also establishes individualised procedures for residents who are likely to be aggressive and cause harm or self-harm, focusing on positive behaviour, ability and willingness. There is a key worker system that allows staff to work on a one to Enmore Lodge DS0000025780.V342437.R01.S.doc Version 5.2 Page 10 one basis and contribute to the care plan for the individual. Care plans are reviewed and updated as required. The staff on duty stated that residents are provided with the information, assistance and communication support they need to make decisions about their own lives. The home recognises the right of individuals to take control of their lives and to make their own decisions and choices. There is some evidence that individuals are involved in some decision making about the home, such as day to day living and social activities. The home recognises the importance of promoting equality and diversity rather than just meeting needs in a reactive manner. The staff stated that a number of residents attend an Afro-Caribbean club on a regular basis. Risk assessments are completed but these are basic and mainly focus on keeping people who use the service safe. The home must ensure that residents’ risk assessments are comprehensive and staff have good information on which to base decisions, within the context of the resident’s individual plan and of the home’s risk assessment and risk management strategies. Enmore Lodge DS0000025780.V342437.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are encouraged to explore opportunities to enhance their quality of life as well as maintain and participate with friends and the local community, with the aim of maximum integration. EVIDENCE: The home encourages all its residents to maintain their life skills and participate in activities appropriate to their abilities. The home also offers inhouse activities. Staff help residents to find out about and take up opportunities for further education and vocational, literacy and numeracy training. Enmore Lodge DS0000025780.V342437.R01.S.doc Version 5.2 Page 12 Residents are able to access a wide range of community activities. All the residents are registered to vote. The home also values and seeks to reflect the racial and cultural diversity of residents and of the community in which it is located. People who use the service are actively encouraged to maintain links with their families and friends. Residents, who were at home at the time of this inspection, appeared to enjoy some level of independence. Routines can be flexible and are well observed to take into account all the residents’ individual needs. The home tries to be flexible and attempts to provide a service that is as individual as possible using its staff and resources effectively. A number of residents commented positively on the care they are receiving. One resident stated, “I have been here a long time and I like it here ”. The meals are balanced and nutritional and cater for the varying cultural and dietary needs of the individuals using the service. Mealtimes are flexible and relaxed, staff are patient and helpful, and allow individuals the time they needed to finish their meal comfortably. Enmore Lodge DS0000025780.V342437.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19, 20 and 21 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall the arrangement for health care needs of the residents is good and they receive personal support in the way they prefer. EVIDENCE: The delivery of personal care is individual and flexible. Staff respect the privacy and dignity of the residents and are sensitive to their changing needs. Where needed, guidance and support regarding personal hygiene (e.g. to wash, shave) is provided. Times for getting up/going to bed, baths, meals and other activities are flexible. The staff group is balanced to enable choice of male, female and age related preferences when delivering personal care. Enmore Lodge DS0000025780.V342437.R01.S.doc Version 5.2 Page 14 People who use services have access to health care services both within the home and in the local community. The residents are able to choose their own GP and attend local dentists, opticians and other community services. The home has an efficient medication policy supported by procedures and practice guidance, which staff understand and follow. Medication records are fully completed, contain required entries, and are signed by appropriate staff. However it was noted that the allergies of the residents are not written on their MAR sheets and this potentially places them at risk. The registered person must ensure that residents’ allergies are recorded on the medication profiles and/or MAR sheets. The home has policies and procedures, which provide guidance for staff on how to support a person and their family when faced with a terminal illness. However the wishes of individuals about terminal care and arrangements after death is not always recorded. The manager must consult the residents and/or their relatives about their last wishes and this needs to be documented in their personal files. Staff must also need to be aware of the resident’s cultural and religious during the dying process. Enmore Lodge DS0000025780.V342437.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Complaints are generally managed well, which should ensure that residents’ and relatives’ concerns are listened to. However there is a lack of understanding of safeguarding procedures and how they work. EVIDENCE: The home has a complaints procedure that is clearly written and easy to understand. The procedure explains how to make a complaint and that the complainant can expect a response about the outcome of any investigation to a complaint within 28 days. There have been concerns raised by one relative with regards to the care of one resident. This was discussed with the manager who stated that the concerns are currently being looked in to by the local Care Management Team. Policies and procedures for safeguarding people who use the service are in place however the staff are not familiar with the guidance. As part of the inspection process two staff were interviewed on their knowledge of reporting alleged abuse. One of the staff stated that he would investigate any incident of alleged abuse. This is very concerning to the Commission as this would contaminate any investigation that would be carried out by the Care Management Team. The home must ensure that all staff are aware of and understand the procedures for Safeguarding Adults. Enmore Lodge DS0000025780.V342437.R01.S.doc Version 5.2 Page 16 It was also noted that staff have limited knowledge on how to deal with residents who can be physically or verbally aggressive. The home must ensure that physical and verbal aggression by a resident is understood and dealt with appropriately. Training around dealing with physical and verbal aggression must also be made available to all staff as needed. Enmore Lodge DS0000025780.V342437.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,26 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is generally hygienic, clean, homely and comfortable however a number of health and safety issues need to be addressed as these potentially place service users and staff at risk. EVIDENCE: The home provides a physical environment that meets the specific needs of the people who live there. The home is comfortable, and has a programme to improve the decoration, fixtures and fittings. Overall the home was decorated to a good standard however it is not complying with fire regulations (see standard 42). Enmore Lodge DS0000025780.V342437.R01.S.doc Version 5.2 Page 18 A tour of the home was carried out and it was noted that some of the rooms look bare and however others were personalised. It was also noted that the carpet on the stairs by the laundry room going up must be replaced, as it looked worn out. The home is kept clean and hygienic and free from offensive odours throughout. Systems are in place to control infection in accordance with relevant legislation and published professional guidance. Enmore Lodge DS0000025780.V342437.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Generally staff numbers are of sufficient quantity to meet the residents’ needs and provide consistency and to ensure their safety. EVIDENCE: There are consistently enough staff available to meet the needs of the people using the service. The staffing structure is based around delivering outcomes for the people using the service. The home has a good recruitment procedure. Two staff files were examined at random and found to contain the information required by the Care Homes Regulations 2001 including a completed job application, terms and conditions of employment, an enhanced CRB check and proof of their identity. The home ensures that all staff within its organisation receives relevant training that is targeted and focussed on improving outcomes for residents. The service uses external providers to deliver this training if they have not got Enmore Lodge DS0000025780.V342437.R01.S.doc Version 5.2 Page 20 the appropriate skills within the organisation. However there are still some areas, which need attention, as not all staff are up to date with regards to their mandatory training. Enmore Lodge DS0000025780.V342437.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is generally managed well however the health, safety and welfare of residents and staff are not being fully promoted/protected and this potentially places them at risk. EVIDENCE: The registered manager has the required experience and is competent to run the home. He works to continuously improve services and provide an increased quality of life for residents. There is a strong ethos of being open and Enmore Lodge DS0000025780.V342437.R01.S.doc Version 5.2 Page 22 transparent in all areas of running of the home. He is also aware of current developments both nationally and by CSCI and plans the service accordingly. The home has an effective quality assurance and quality monitoring systems, based on seeking the views of service users, to measure success in achieving the aims, objectives and statement of purpose of the home. A number of health and safety records were checked and most of them were up to date. However it was noted that the fire extinguishers have not been serviced during the last 12 months. The registered provider must ensure that all fire extinguishers are maintained at a regular interval that is yearly. A number of windows were opening wide on the first and second floor. Although they have restrictors on them these could be overridden. However the manager stated that the residents would not be able to override the restrictors. It was agreed that the home would carry out a risk assessment on each resident regarding this issue and this would be documented on their personal files. Enmore Lodge DS0000025780.V342437.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 X 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 1 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 2 3 X 3 X X 2 X Enmore Lodge DS0000025780.V342437.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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 YA6 Regulation 15(1) Requirement The home must ensure that care plans cover all aspects of personal and social support and healthcare needs of the residents. This will help in meeting their current and changing needs, aspirations and achieve goals. The plan must also establishes individualised procedures for residents who are likely to be aggressive and cause harm or self-harm, focusing on positive behaviour, ability and willingness. The home must ensure that residents’ risk assessments are comprehensive and staff have good information on which to base decisions, within the context of the resident’s individual plan and of the home’s risk assessment and risk management strategies. The registered person must ensure that residents’ allergies DS0000025780.V342437.R01.S.doc Timescale for action 28/11/07 2 YA6 15(1) 28/11/07 3 YA9 13(4) 28/11/07 4 YA20 13(2) 14/08/07 Enmore Lodge Version 5.2 Page 25 are recorded on the medication profiles and/or MAR sheets. 5 YA21 15(1) The manager must consult the residents and/or their relatives about their last wishes and this needs to be documented in their personal files. The home must ensure that all staff are aware of and understand the procedures for Safeguarding Adults. 28/11/07 6 YA23 13(6) 28/11/07 7 YA23 13(6) The home must ensure that 28/11/07 physical and verbal aggression by a resident is understood and dealt with appropriately. Training around dealing with physical and verbal aggression must also be made available to all staff as needed. The carpet on the stairs by the laundry room going up must be replaced as it was worn out. The home must ensure that all staff are up to date with regards to their mandatory training. The registered provider must ensure that all fire extinguishers are maintained at a regular interval that is yearly. 28/11/07 8 YA24 13(4) 9 YA35 18(1) 28/11/07 10 YA42 13(4) 14/08/07 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.V342437.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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