Inspection on 08/12/05 for Jordan Lodge

This inspection was carried out on 8th December 2005.

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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Jordan Lodge 08/11/07

Jordan Lodge 11/09/06

Jordan Lodge 04/08/05

Jordan Lodge 27/01/05

Jordan Lodge 15/07/04

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Jordan Lodge 5 Warham Road South Croydon Surrey CR2 6LE Lead Inspector Margaret Lynes Unannounced Inspection 8th December 2005 2:15pm Jordan Lodge DS0000025803.V271109.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 Jordan Lodge DS0000025803.V271109.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. Jordan Lodge DS0000025803.V271109.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Jordan Lodge Address 5 Warham Road South Croydon Surrey CR2 6LE 020 8686 8801 020 8668 3212 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) Laurel Residential Homes Limited Mr Jeremy R Burrows Care Home 14 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (14) of places Jordan Lodge DS0000025803.V271109.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th August 2005 Brief Description of the Service: Jordan Lodge is a large detached building in South Croydon, well situated for access to the centre of Croydon and its many community based facilities, and good transport links. The property comprises of 2 day rooms (lounge and dining area) on the ground floor, and a small coffee/smoking room on the first. There are 14 single bedrooms, all fitted with hand basins but no other en-suite facilities. There are 3 WC’s, 3 bathrooms and 1 shower. Off-street parking is provided to the front of the house, while there is a large, pleasant garden at the rear. The stated aim of the home is to provide care for people with longterm mental health problems. Jordan Lodge DS0000025803.V271109.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of this visit was to determine if the requirements that were made following the last inspection had been dealt with. The visit itself was conducted over the course of several hours, and included talking with residents and staff, examination of records and a brief tour of parts of the home. The last visit resulted in nine new requirements, while there were a further ten requirements that remained outstanding from previous inspection visits. This visit indicated that a great majority of these have now been met. What the service does well: 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. Jordan Lodge DS0000025803.V271109.R01.S.doc Version 5.0 Page 6 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 Jordan Lodge DS0000025803.V271109.R01.S.doc Version 5.0 Page 7 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): 2 The Inspector was satisfied that adequate assessments were being made of prospective service users. This means that service users can be assured that the home has taken into account their individual needs, and that it can meet them; and that the staff in the home will be as familiar as they can be with new service users, and have a full understanding of what specific service they will need to provide. EVIDENCE: The files of two new service users were examined. Both contained satisfactory pre-admission assessments. This means that the home has complied with the previously made requirement. Jordan Lodge DS0000025803.V271109.R01.S.doc Version 5.0 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 and 9 While improvements had certainly been made in the care plans, it was still not felt that they adequately reflected how assessed needs and goals were to be met, or if they had been met. This means that it is difficult for the staff team to determine if progress is being made, and the feedback for service users may not be as positive as it could be. Notable improvements had been made to the risk assessment process, however not all of the service user files inspected contained such an assessment. This means that the Inspector could not be wholly satisfied that all risks to service users had been fully measured, or that the service users were being supported to take risks as part of an independent lifestyle. EVIDENCE: At the previous inspection a requirement was made regarding the need for more comprehensive documentation to indicate how service user needs were being met. This visit indicated that there has been an improvement in the actual documenting of individual needs however the evidence as to how those needs were being met was not substantiated to any great degree. Jordan Lodge DS0000025803.V271109.R01.S.doc Version 5.0 Page 9 For example, in one service user file an identified need was for the resident to participate in cooking their meals. There was nothing in the progress notes (on the dates inspected) to suggest that this had ever been done. At the time of the last inspection there were no risk assessments in the files examined. Clearly it is important that each service user has a clear risk assessment, both for their protection and the protection of other residents, staff and the community at large. On this visit, risk assessments were seen in four of the five files inspected. While the previously made requirement will be repeated, there has been a clear improvement in this crucial area. Jordan Lodge DS0000025803.V271109.R01.S.doc Version 5.0 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 the following standard(s): 12, 13 and 14 From discussion with service users and staff, and also from observation, the Inspector was satisfied that service users were being given sufficient opportunity to participate in the local community or engage in appropriate activities. This means that they are being provided with sufficient stimulation, which in turn should improve their overall well-being and their enjoyment of day to day life in the home. EVIDENCE: At the last inspection concerns were documented regarding the apparent lack of stimulation, activities and community participation in the home. It was not felt that this was due to lack of staff interest or wish to engage the service users, but rather from a lack of resources. On this visit, residents and staff were clearly engaging well. Residents expressed their satisfaction with the home. It must be said however, that while no further requirements have been made re this Standard, as service users indicated that they were satisfied, there does need to be better evidencing of how staff are meeting service users social needs. Jordan Lodge DS0000025803.V271109.R01.S.doc Version 5.0 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 the following standard(s): 20 The medication administration records were examined. While the records were much improved, one gap was noted. It was again reiterated that staff must be vigilant in this respect as mistakes can have serious consequences for the service users. EVIDENCE: At the last inspection a number of issues were raised regarding the storage and administration of medication. It was pleasing to note that improvements had been made, and undoubtedly the staff team as a whole will be disappointed that a gap in the records was found. Jordan Lodge DS0000025803.V271109.R01.S.doc Version 5.0 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 the following standard(s): 23 Following recent training, staff should have a better understanding of safeguarding vulnerable people. This means that the service users should be protected from abuse. EVIDENCE: Following a requirement in the last inspection report regarding the need for all staff to be enabled to attend training in adult protection, in-house training has taken place. The appropriate procedures were also in place. Jordan Lodge DS0000025803.V271109.R01.S.doc Version 5.0 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 the following standard(s): 24 and 27 See comments below. EVIDENCE: At the last inspection a number of requirements were made with regard to the premises. These concerned the need to replace the flooring in the first floor hallway and the first floor WC, to resolve the ongoing issues re the temperature of the hot water, and to install a diffuser on the first floor landing. The latter has been done while flooring has been purchased and a new boiler is due to be installed shortly. For this reason, the requirements have not been repeated however neither have the Standards been ‘scored’, as until the work has been completed the Standards cannot be said to have been met. Jordan Lodge DS0000025803.V271109.R01.S.doc Version 5.0 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 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): 33 Concerns raised previously regarding staff being stretched, and unable to devote the individual time to service users that they should, due to having to cover catering duties, have been resolved. This means that the service users can be supported by a more effective staff team. EVIDENCE: At the time of the last visit it appeared that staff were not always able to spend time with individual service users (i.e. on 1:1 sessions, going out on activities etc) because they had to prepare the main meals and at the same time ensure the well-being of all residents. On this visit, this issue had been (temporarily) resolved by all staff agreeing to work overtime once a week so as to cover the cooking. Ongoing efforts are still being made to engage a cook. Jordan Lodge DS0000025803.V271109.R01.S.doc Version 5.0 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 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): 39, 40, 41 and 42 The Inspector was still not fully satisfied that the home was being run in the best interests of the service users as the quality assurance system still needed to be expanded and include regular audits. The policies and procedures missing at the time of the last inspection were now in place, thus contributing to promoting the welfare of the service users. Standard 41 could still not be said to have been met due to the minor error found in the medication charts. In this respect, therefore, the service users best interests were not being as safeguarded as possible. Previously made requirements re health and safety matters had been dealt with. It was felt on this visit therefore, that the health safety and welfare of the service users was, in this respect, being promoted and protected. Jordan Lodge DS0000025803.V271109.R01.S.doc Version 5.0 Page 16 EVIDENCE: While, as commented on in the report of the last inspection, the home does have a quality assurance system, it still has yet to be fully developed. The manager and senior staff contribute to the ‘QA’ file on a regular basis however there is still a need for the manager (or for him to delegate) to carry out regular audits of the various systems in the home (i.e. keyworking, record keeping, medication, catering, housekeeping) and to evidence these audits. It was previously required that the main policy and procedure manual contain both the complaints and the adult protection procedures. These were both available on this visit. Due to the one error found in the medication administration records it was not possible to evidence that the Standard (41) re record keeping was wholly met. The requirement re the medication charts has been repeated but a separate requirement re record keeping has not been made, albeit the scoring for this Standard is only 2. The requirements previously made regarding health and safety matters in the home have all been dealt with. These related to the need for the fire alarms to be tested on a weekly basis, daily fridge/freezer temperature readings, the need to replace the condemned fire extinguisher, and the need to ensure that windows above ground floor level had appropriate restrictors fitted. Jordan Lodge DS0000025803.V271109.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X X X Standard No 22 23 Score X 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X 2 X 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 3 14 3 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X 3 X X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Jordan Lodge Score X X 2 X Standard No 37 38 39 40 41 42 43 Score X 3 2 3 2 3 X DS0000025803.V271109.R01.S.doc Version 5.0 Page 18 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 YA6 Regulation 12 Requirement Timescale for action 31/01/06 2 YA9 13 3 YA20 13 4 YA39 24 The staff team needs to better evidence how the services being provided are meeting the assessed needs and goals of the service users (as identified in the service user plans). The previously set timescale has not been fully met, however improvements have been made. Risk assessments must be 31/12/05 carried out for all service users. These should be documented and regularly reviewed. The manager must ensure that 08/12/05 the medication administration records are accurately maintained at all times. Improvements were noted however the records were not fully accurate. An appropriate quality assurance 31/01/06 system must be implemented in the home, which seeks service users views and measures the success of the home in meeting the aims and objectives laid out in the Statement of Purpose. A system has been devised but has yet to be implemented. The previously set timescale has not DS0000025803.V271109.R01.S.doc Version 5.0 Jordan Lodge Page 19 been met. 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 Jordan Lodge DS0000025803.V271109.R01.S.doc Version 5.0 Page 20 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. 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