Inspection on 06/12/05 for Lavenders (The)

This inspection was carried out on 6th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lavenders (The) 19/01/09

Lavenders (The) 22/02/07

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 09/07/2008.

CARE HOME ADULTS 18-65 Lavenders (The) 145a Friern Park Finchley London N12 9LR Lead Inspector Tola Akinde-Hummel Unannounced Inspection 6th December 2005 09:00 Lavenders (The) DS0000065434.V265247.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 Lavenders (The) DS0000065434.V265247.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. Lavenders (The) DS0000065434.V265247.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Lavenders (The) Address 145a Friern Park Finchley London N12 9LR 020 8445 9978 020 8445 9974 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) CareTech Community Services (No.2) Ltd Care Home 8 Category(ies) of Learning disability (8), Physical disability (8) registration, with number of places Lavenders (The) DS0000065434.V265247.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The bungalow is registered to provide two of the establishment`s eight places, the remaining six being provided in the main building. One bungalow (145b) can accommodate a wheelchair dependent service user. The call system within the bungalow must be fully functioning at all times. The second bungalow (145c) is not suitable for a wheelchair dependent service user. 16 June 2005 2. 3. Date of last inspection Brief Description of the Service: The Lavenders is a nursing home for 6 adults who have learning and physical disabilities. There is an adjacent building which accommodates two people in self contained accommodation. The home is owned and managed by CareTech Community Services Ltd. The home which is located in a quiet residential street in North Finchley, is set back from the main road, and is within walking distance of shops and other amenities. There is a qualified nurse on duty at all times. The service users that live in the bungalow are also assisted by staff in the main building. The stated aim of the home is to work in partnership with the service users, their carers, purchasers and any other relevant agencies providing an individual support plan for each user of the service, with users being encouraged to attain their full potential determined by individual need. Lavenders (The) DS0000065434.V265247.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took approximately five hours to complete. The manager Ms Loraine Allen was present throughout the inspection. At the time of inspection there were three service users in the home. Three staff members plus the manager were available in the morning and five staff members were available in the home in the afternoon when handover took place, then leaving three staff plus the manager. The inspector was able to speak briefly to one service user and another in more depth. The other service user in the home has limited verbal communication. The inspector was able to speak to two relatives visiting the home. The inspector also spoke to the manager and two members of staff. The inspector had a tour of the building, looked at care plans, health and safety records, personnel files and looked at requirements from the previous inspection. The inspector would like to thank all service users, relatives and staff for their assistance during the inspection. What the service does well: What has improved since the last inspection? As the Lavenders service user group has changed, some of the requirements from the previous inspection are no longer relevant. The service users guide now contains the contact details of the commission and the recording of complaints and their outcomes meet the standards. Lavenders (The) DS0000065434.V265247.R01.S.doc Version 5.0 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. Lavenders (The) DS0000065434.V265247.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 Lavenders (The) DS0000065434.V265247.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): 1,2,4, 5 Prospective service users needs are appropriately assessed prior to entering the home. The Lavenders also welcomes prospective service users and their families to visit prior to admission. The statement of purpose requires some updating and the contract for service users must be prepared in a format that service users understand. EVIDENCE: The Lavenders reopened in July 2005. To date there are four service users in the main building and two service users living in the bungalow. Records show that service users and their relatives visit the home prior to admission. On the day of inspection a relative of a prospective service user was visiting. This relative spoke fluent French and was able to communicate in this language with a senior member of staff to get a good idea about the facilities available. Service users enter the home initially for a visit then have a series of overnight stays. Two service user care plans were examined. These showed that prior to admission full assessments have been carried out. These assessments were carried out by Care managers and follow up assessments are completed by the home. The Lavenders statement of purpose does not contain the name or relevant qualifications or experience of the registered manager or the staff team. This must be amended to include the above. The service user guide contains all the relevant information. However, there is no contract available to service users which must be written in a format that can be understood. When asked, one service user said, “ I do not remember signing a contract Lavenders (The) DS0000065434.V265247.R01.S.doc Version 5.0 Page 9 when I came here”. Lavenders (The) DS0000065434.V265247.R01.S.doc Version 5.0 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): 6,7,8,9 Service users can be confident that their changing needs are recognised and acted upon. Service users are central to the development of the home and their opinions are regularly sought and are actively encouraged to participate in decision-making. EVIDENCE: No service user in the home has been resident for longer than five months, however there are monthly reviews of plans in place of service users progress, which ensure that any changing needs are recognised and met. The two plans inspected clearly indicate the health and social needs of service users. Records show the involvement of various health professionals in promoting the wellbeing of service users. The plans describe how service users like to be assisted and what their dislikes are. These plans are person centered and respect the individual. One service user in the home at the time of inspection said, “ This is a good place because they realised I had medical needs that had gone unnoticed for a long time” Two service users with verbal communication were able to describe the choices they have within the home. One service user was in the process of arranging an overnight stay with friends and was very clear about what was required of Lavenders (The) DS0000065434.V265247.R01.S.doc Version 5.0 Page 11 the home to make this happen. This was negotiated with the manager and agreed. Service users are supported to develop their independence and levels of responsibility according to their ability and inertest. This includes participating in the shopping, preparing drinks and arranging social events. One service user is a fire warden in the home. On the day of inspection the fire alarms were tested. The service user stated “ I have been trained to do this and I will be helping to train other people in the home to do this also. I have done evacuations and will be doing a night evacuation in the near future”. Staff confirmed this level of responsibility. The home has detailed risk assessments of service users on file with information on how risks can be minimised. These are up to date. Lavenders (The) DS0000065434.V265247.R01.S.doc Version 5.0 Page 12 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): 12,14,16,17 Service users are involved in making decisions about how their leisure time is spent and are included in the planning and purchasing of food in the home. Service users are comfortable in their relationships with staff and access all areas of the home. EVIDENCE: One service user spoken to at the time of inspection explained that he attends a day centre where he is a volunteer. The service user is an IT trainer and enjoys this role. Other service users attend day centres and clubs in the evening. One service user attends church regularly with relatives and is visited by a priest and a sister. The service users bedroom reflects his religious beliefs. Service users enjoy planning their social life and with staff, make decisions about where they wish to socialise. A relative informed the inspector “ My daughter loves it here there is a lounge so she always has company and now she doesn’t want to come home and stay” On the day of inspection one service user entered another service users bedroom without permission. It was made very clear that this is not acceptable and privacy should be respected at all times. Throughout the day staff were seen interacting with service users, this was open, friendly and positive. There Lavenders (The) DS0000065434.V265247.R01.S.doc Version 5.0 Page 13 is a varied staff mix that reflects the background of some service users, particularly those from ethnic backgrounds, however staff are familiar with the particular cultures of all service users and respect these. Communal areas of the home are not restricted to service users. The inspector observed service users enter the office and speak to staff socially or on serious matters. One relative said, “ I am really pleased that staff are comfortable allowing people who live here to show affection. There is no rejection from staff, this is really spot on”. During a tour of the building, it was evident that staff are labelling food and the food on offer to service users is varied, healthy and nutritious. On relative stated, the food here is good and my son has put on weight. If relatives come around mealtimes we are invited to eat”. One service user also added, “The food is good, I have no complaints” Lavenders (The) DS0000065434.V265247.R01.S.doc Version 5.0 Page 14 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): 18,19,20 The home respects the personal preferences of service users when providing personal care thereby promoting independence and choice. Lavenders ensure that the health needs of service users are addressed. The recording and administration of medication is thorough. EVIDENCE: Care plans detail how service users like to be supported with their personal care. These are person centered and describe the need for staff to ask how service users wish to be supported and develop a daily dialogue in the case of personal care. Daily notes demonstrate that service users choose the amount of support they require on any day. One service user explained that he currently only receives support from male carers three times a week due to a shortage of male staff. The service user has discussed this in detail with the manager and the manager confirmed to the inspector that recruitment is under way to address this. The service user added “ Two senior carers provide my personal care and I am happy with that until a male member of staff can be identified. They know my routine and support me very well”. The home has an adequate supply of equipment to maximise support and independence. Service user plans indicate where specialist support is provided. All service users are registered with a GP, and have access to other primary health care services. Records of medical intervention are recorded on service user files. One senior Lavenders (The) DS0000065434.V265247.R01.S.doc Version 5.0 Page 15 carer explained, “ When a new service user enters the home, they are initially supported by a senior carer to ensure that their needs are properly understood”. After some time, the service user is allocated a key worker who will shadow the senior carer to ensure care provided is of a high standard and relevant. One service user has complex medical needs that previously required weekly district nurse intervention. The district nurse trained all staff to manage the health needs of the service user and in turn the senior care staff trained the waking night staff to manage these needs. All staff members have completed Boots medication training. The manager has applied for all staff to complete the intensive safe handling of medication training in the New Year. Medication in the home is securely stored with a separate cabinet for controlled drugs. The medication has been organised by the senior carers. Inspection of the medication found all records complete with additional information recorded on the reverse of the MAR sheet. Copies of staff signatures are in place to enable clear audit trails. Lavenders (The) DS0000065434.V265247.R01.S.doc Version 5.0 Page 16 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): 22,23 The Lavenders ensures that service users and visitors to the home have access to the complaints procedure and know how to use this. Thereby ensuring that complaints are taken seriously. The issue of whistle blowing remains outstanding and information must be provided to staff in order to ensure all care responsibilities are fulfilled. EVIDENCE: The Lavenders clearly advertise their complaint procedure around the home. Information is displayed in the hall where visitors sign on entry. The home also displays the details of the commission to assist visitors and service users who wish to complain. This is done in written and pictorial form to ensure service users have access. There have been two complaints since the previous inspection both of which have been resolved. One service user stated, “ I know how to complain, I am very vocal, they know if I am not happy I will say something”. The inspector witnessed another service user enter the office and express a concern to the manager this was taken seriously and followed up. The home has a policy on the protection of vulnerable adults and all staff have been trained in this area. At the previous inspection, a requirement was made to ensure that there was a whistle blowing policy in the home. This has not been addressed. This means that staff remain unclear about the company policy and procedure on whistle blowing. This must be addressed. Lavenders (The) DS0000065434.V265247.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26,30, Service users live in an environment that is clean comfortable and friendly. This ensures that service users recognise the Lavenders as their home. EVIDENCE: The Lavenders is warm and welcoming. The home is bright and airy and the furnishings and fittings in the home are of a good standard. The home is wheelchair accessible in all areas. The bathrooms are equipped with assisted baths and the senior carer advised that water temperatures are taken prior to any service user having a bath. The home has a fish tank which service users and staff take an interest in. One relative said, “ The home is clean, always absolutely spotless, I buy food for the fish and my son bought a timer for the tank”. Another relative stated, “ The atmosphere here is nice and my son asks to return to here when he has been away”. One vacant and one occupied service user bedroom was seen. The unoccupied room was well furnished with a bed, chest of draws and wardrobe. Curtains maintain privacy and service users are able to personalise their bedrooms as they wish. The occupied bedroom is personalised to suit the needs of the service user with items including colourful bed linen, a television and family pictures on the walls. Lavenders (The) DS0000065434.V265247.R01.S.doc Version 5.0 Page 18 Lavenders (The) DS0000065434.V265247.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 Staff access training relevant to their roles. This ensures that support to service users is appropriate and sensitive. Service users can be assured that the recruitment of staff to the home is robust and minimises the risk of appointment of unsuitable individuals. EVIDENCE: With the exception of two staff members all staff in the home have been employed from July 2005 onwards, including the manager. During the course of the day, the inspector observed positive communication between staff and service users. Staff members joked with service users and service users communicate with each other in a relaxed and friendly manner. The manager stated that relationships have developed with health and social services professionals to ensure that the needs of service users are understood and any action taken is done so in partnership. The inspector looked at the personnel files of two staff and found that staff members are properly recruited and the necessary checks have been carried out prior to appointment. All new staff members have completed the mandatory training and evidence of written tests relating to the training in adult protection, fire safety and emergency first aid were seen. In total there are 16 staff working in the home. Five care staff work full time, six care staff work part time and four waking night staff work both full and part Lavenders (The) DS0000065434.V265247.R01.S.doc Version 5.0 Page 20 time. The home also has a full time driver. One staff member has achieved NVQ level 2;S another is working on level 3. Four staff members are undertaking NVQ level 2 and the remaining staff members are on foundation training. Lavenders (The) DS0000065434.V265247.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 38, 42 An inclusive style of management has developed that places the service user at the centre of the homes future direction. Health and safety testing is carried out regularly. However the hold open door devices must be replaced to maximise safety in the event of a fire. EVIDENCE: The Lavenders reopened in July 2005. The present manager has been in post since August 2005. The majority of staff are new to the home but have had experience in the care sector. The staff team have a good relationship with the manager. One staff member stated, “ This is the best manager I have worked with, I feel supported, you can approach her and she encourages you to undertake training”. On discussion with the manager it became clear that she has clear ideas about the direction in which the home should move and central to this are the needs and aspirations of the service users. Service users are included in all aspects of the home. One service user said, “ The manager is good she is not bossy, she is the best I’ve ever seen, every thing they do, they do with us”. As mentioned above one service user is a fire warden in the home Lavenders (The) DS0000065434.V265247.R01.S.doc Version 5.0 Page 22 This responsibility is taken seriously and respected by staff and other service user. Staff members are also encouraged to share good practice. The Lavenders have regular fire alarm tests and drills these are recorded and are up to date. During the fire alarm test at the time of inspection, the hold open door devices were taking too long to release the doors following the sound of the alarm. This would seriously compromise the health and safety of all people in the home in the event of a fire. The home must replace these devices or connect these to the central alarm. Food in the home is correctly stored and labelled. Records show that the electrical equipment such as hoists is regularly serviced. The home also has the insurance certificate and certificate of vehicle insurance on display. Lavenders (The) DS0000065434.V265247.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 X 3 1 Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X 3 X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 X 14 3 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Lavenders (The) Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score X 3 X X X 2 X DS0000065434.V265247.R01.S.doc Version 5.0 Page 24 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation 4 (1) (c) Schedule 1 Requirement The registered person must ensure that the statement of purpose contains the name of the registered manager and details of qualifications of staff in the home. The registered person must ensure that service users are given a contract that is produced in a format they understand and where necessary representatives are available to assist. The registered person must ensure that staff have access to and are familiar with the whistleblowing policy. The registered person must ensure that the hold open devices on all doors are replaced to ensure that when the fire alarm goes off the doors close within a reasonable time. Timescale for action 30/01/06 2 YA5 5 (b) (c) 30/01/06 3 YA23 13 (6) 30/01/06 4 YA42 23 (4)(a) (c) 28/02/06 Lavenders (The) DS0000065434.V265247.R01.S.doc Version 5.0 Page 25 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 Lavenders (The) DS0000065434.V265247.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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 Lavenders (The) DS0000065434.V265247.R01.S.doc Version 5.0 Page 27 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!