Inspection on 19/07/05 for Lodge Hill (169)

This inspection was carried out on 19th July 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Lodge Hill (169) 16/11/06

Lodge Hill (169) 09/01/06

Lodge Hill (169) 09/03/05

Lodge Hill (169) 21/09/04

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Edenvale

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Chatsworth Care - Dawson House

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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 18-65 169 Lodge Hill Abbey Wood London SE2 OAS Lead Inspector Keith Izzard Announced 19 July 2005 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 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 Stationary 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. 169 Lodge Hill G51-G01 S36906 Lodge Hill V231966 19-07-05 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 169 Lodge Hill Address 169 Lodge Hill, Abbey Wood, London SE2 OAS 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) 0208 311 1139 feizalglo@yahoo.co.uk Greenwich Council Mr Feizal Rajabally Care Home 6 Category(ies) of Learning Disability - 6 registration, with number of places 169 Lodge Hill G51-G01 S36906 Lodge Hill V231966 19-07-05 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 9/03/05 Brief Description of the Service: 169 Lodge Hill is a modern chalet style building situated in the grounds of the former Goldie Leigh hospital close to the facilities of Welling and Bexleyheath. There are six single bedrooms providing accommodation for service users with moderate to severe learning difficulties and physical disability. There is one vacancy as one undersized room is being reviewed for a possible building extensioninj order to meet current Standards. Four rooms are located on the ground floor two of which are suited for two service users who use wheelchairs and have access to the downstairs bathroom and separate walk in shower. The lounge and kitchen diner area are also located on the ground floor. There is level access to the small garden and patio area from the kitchen diner. Upstairs are a further two service user bedrooms a combined bathroom and toilet and the staff sleep in room / office. The home is run by the London Borough of Greenwich. A staff team of eight are supported by a manager and deputy manager and provide 24 hr cover for the home. Service users attend local day centres during weekdays and are provided with personal care and support to live as independently as possible and to take part in activities both within the home and the community. Residents are encouraged to personalise their own room, meals,laundry and care support,are provided by staff. 169 Lodge Hill G51-G01 S36906 Lodge Hill V231966 19-07-05 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection carried out on one day over a period of seven hours. Since the previous inspection one resident has moved from the home in order to better meet his assessed needs for ground floor accommodation. The home was clean, tidy and safe and staff members were observed to be both caring and professional in the way they related to the resident at home at the time of inspection. The residents observed, appeared to be happy in their home and related well to staff members. One of the residents initiated a conversation and he described enthusiastically what his programme was for the day and also took pleasure showing the Inspector his room. The inspection provided for two interviews with residents and the records for both were examined in detail to evidence the consistency of information provided. Also, an interview took place with a member of the care staff and both the deputy and manager. Care files were examined as were documents relating to health and safety and staffing. The building was also inspected throughout. In general terms the home was operating to a satisfactory standard and had complied with previous requirements and recommendations. Residents and staff members, both observed and interviewed, appeared to have a good rapport. Residents appeared to be contented within their home supported by caring and professional staff. What the service does well: Staff and the manager communicated positively with relatives and advocates and worked with them and residents to meet individual needs and provide residents with a lifestyle suited to them. 169 Lodge Hill G51-G01 S36906 Lodge Hill V231966 19-07-05 Stage 4.doc Version 1.40 Page 6 Good communications existed with the local Community Learning Disability Team and other health and social service officials to enhance the quality of care provided in the home. Staff received training and supervision to enable them to fulfil their role. Records were well maintained and care plans were up to date and reflected resident needs. Staff spoke respectfully about the residents and showed insight and knowledge into their needs. Staff members of the home facilitated an observer from the CSCI on the day of inspection. This was much appreciated. 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. 169 Lodge Hill G51-G01 S36906 Lodge Hill V231966 19-07-05 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection 169 Lodge Hill G51-G01 S36906 Lodge Hill V231966 19-07-05 Stage 4.doc Version 1.40 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 standard(s) 1-5 Adequate information was provided about the service in the statement of purpose and service user guide to enable prospective residents to make a decision to the suitability of the service. Admission procedures were in place to comply with these standards. EVIDENCE: The home had a statement of purpose and service user guide. The admission procedures in place complied with requirement. As one new resident had been admitted since the introduction of the National Minimum Standards the procedure was assessed at a previous inspection and had been complied with. Since that time there have not been any further new admissions. Contracts for residents had been provided that met this Standard. 169 Lodge Hill G51-G01 S36906 Lodge Hill V231966 19-07-05 Stage 4.doc Version 1.40 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 standard(s) 6-10 Care plans and risk assessments viewed were up to date and comprehensive and reviewed on a regular basis. Annual Life Plans were also up to date and showed that residents were involved and family or representatives and professionals involved had been invited. Residents were involved in decisions about them and records about them were handled appropriately to maintain confidentiality. EVIDENCE: Care provided to two residents was tracked. Care plans were well written and were supported by up to date assessment of need and individual risk assessments. It was evident in the care plans that residents or relatives were involved in care planning. 169 Lodge Hill G51-G01 S36906 Lodge Hill V231966 19-07-05 Stage 4.doc Version 1.40 Page 10 Staff interviewed said they endeavoured to involve residents in decision affecting them as best they can, taking into account their individual communication difficulties. Staff members were observed communicating with residents and involving individuals in whatever was going on, throughout the inspection. Records were appropriately managed and stored securely. 169 Lodge Hill G51-G01 S36906 Lodge Hill V231966 19-07-05 Stage 4.doc Version 1.40 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 standard(s) 11-17 Attention was given to meeting the leisure and social needs of the residents. Meals provided were varied and planned to meet the resident’s choice and preferences. EVIDENCE: Residents attended day centres or other outside agencies where they had the opportunity to develop life skills. Staff supported residents to develop daily living skills in line with their individual ability. Records showed that residents were supported to access leisure activities of their choice and to integrate with the community. A range of outings, for example, visits to pubs, cinemas, shops, parks, games, sightseeing and annual holidays were recorded. 169 Lodge Hill G51-G01 S36906 Lodge Hill V231966 19-07-05 Stage 4.doc Version 1.40 Page 12 The provision of outings is partly dependant on the availability of staff who are able to drive the mini bus, continued efforts should be made to maximise staff availability in this respect. Recommendation 1 Residents were enabled to choose their own clothes and hairstyles, when accompanied by staff members on shopping trips and to personalise their rooms with their choice of decoration, furnishings and personal possessions. Nearly all residents have regular outside contact either from relatives, direct payment workers, or through the provision of an advocate. However, it was noted that one resident has diminishing contact from relatives and this resident must be provided with an advocate in order to provide an independent voice for her. The increasing health issues for this resident should be reviewed to ascertain whether this impacts on her ability to take part in activities and if so how this should be addressed. Requirement 1 & Recommendation 2 169 Lodge Hill G51-G01 S36906 Lodge Hill V231966 19-07-05 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18-21 Resident’s needs were being met based on assessment of need and with the involvement of the resident. Medicines were safely managed. EVIDENCE: Care plans and daily records showed how personal care was provided. Staff interviewed spoke with knowledge and confidence about resident’s individual needs and preferences. Residents were supported to access health services appropriately and these were provided either in the home or by attendance at local clinics and surgeries. Evidence was available from care files and daily diaries in respect of service users that a wide range of health and related professionals are commissioned to attend to heath needs on a regular basis and that this is reviewed. For example, the provision of a specialist wheelchair and a request for a ceiling track hoist to be provided for one resident. 169 Lodge Hill G51-G01 S36906 Lodge Hill V231966 19-07-05 Stage 4.doc Version 1.40 Page 14 Requirement 2 Close links were maintained with the local Community Learning Disability Team. The medication system was examined and was found to be well organised. However, it was recommended that the temperature of the room for storing medication is regularly monitored to ensure that the temperature does not exceed 25c and action taken if this does occur. Recommendation 3 The issues relating to Standard 21 have been met or are underway. 169 Lodge Hill G51-G01 S36906 Lodge Hill V231966 19-07-05 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22-23 Adequate systems were in place to ensure residents were protected from abuse and to manage complaints about the service. EVIDENCE: The home had policies and procedures to deal with complaints and allegations of abuse. Staff members have received training on adult protection. Any suspicions or allegations of abuse would be referred to the CLDT for investigation under adult protection procedures, as would any unexplained injuries. There were no allegations of abuse made about the service to the home or the Commission since the last inspection. No complaints had been received by the home or the CSCI. The system for dealing with residents’ finance will be assessed at the next inspection. 169 Lodge Hill G51-G01 S36906 Lodge Hill V231966 19-07-05 Stage 4.doc Version 1.40 Page 16 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 standard(s) 24-30 The premises were homely in appearance and decorated to a satisfactory standard. Individual and communal accommodation suited residents’ needs except that one resident requires a ceiling track hoist to be installed in her bedroom. EVIDENCE: Overall the standard of accommodation was good. As mentioned a ceiling track hoist is required for one resident to assist staff members with transfers. Requirement 2. The upstairs bathroom floor is in need of refurbishment and the manager stated that this matter was in hand. Recommendation 4 169 Lodge Hill G51-G01 S36906 Lodge Hill V231966 19-07-05 Stage 4.doc Version 1.40 Page 17 It was noted that the paving area around the home is uneven in places representing a trip hazard for some residents. This must be attended to as soon as possible to prevent accidents occurring. The front entrance area to the building is still subject to flooding and this situation should be investigated and remedied. Requirement 3 & Recommendation 5 The home was clean and tidy and no unpleasant odours were present. 169 Lodge Hill G51-G01 S36906 Lodge Hill V231966 19-07-05 Stage 4.doc Version 1.40 Page 18 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31-33 &35&36 Staff members were clear about their roles and responsibilities, competent and qualified to adequately meet residents’ needs and were supported well by the manager and deputy. EVIDENCE: The manager is both experienced and competent and is due to complete the manager NVQ level 4 by 2006. Staff members interviewed were knowledgeable regarding the needs of residents and observed in practice to be professional and caring in the way they related to residents. The home currently employs the required 50 qualified to level 2 NVQ and evidence was available from training files examined that the required level of specific training was being provided and planned for staff for staff members. The increasing needs of one resident, requiring a greater input from staff, should be reviewed in respect of whether additional staffing hours is required. Recommendation 6 Recruitment policies and procedures will be examined at the next inspection. 169 Lodge Hill G51-G01 S36906 Lodge Hill V231966 19-07-05 Stage 4.doc Version 1.40 Page 19 Supervision records were examined and were found to be slightly below the required frequency of six times per year, in other respects the Standard was met. Recommendation 7 169 Lodge Hill G51-G01 S36906 Lodge Hill V231966 19-07-05 Stage 4.doc Version 1.40 Page 20 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37-43 The management approach to the home benefits residents and provides good leadership. Policies and procedures were in place and records examined showed residents’ rights were both promoted and safeguarded and good attention paid to health and safety matters. EVIDENCE: The manager is both experienced and competent and is due to complete NVQ level 4 by 2006. Staff members reported that the manager was approachable and evidence from the minutes of team meetings and other records showed that residents benefit from good management and leadership of the staff team. 169 Lodge Hill G51-G01 S36906 Lodge Hill V231966 19-07-05 Stage 4.doc Version 1.40 Page 21 A large number of relative and visiting professionals submitted comment cards, which indicated a positive and inclusive working relationship with the service. This was a commendable response. However, the manager does need to introduce a survey of the views of residents, relatives, advocates, and involved outside professionals, at least annually. Requirement 4 Policies and procedures were in place and records maintained that showed that residents’ rights were both promoted and safeguarded. The policies and procedures in place ensured the safety and protection of residents were addressed. A sample of safety records including fire safety were inspected and showed systems and equipment were maintained and regularly serviced. 169 Lodge Hill G51-G01 S36906 Lodge Hill V231966 19-07-05 Stage 4.doc Version 1.40 Page 22 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 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 x 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 169 Lodge Hill Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 3 3 2 3 3 3 3 G51-G01 S36906 Lodge Hill V231966 19-07-05 Stage 4.doc Version 1.40 Page 23 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 18 Regulation 23 Requirement The Registered Person must ensure that a ceiling track hoist is installed for a resident asoon as practicable. The Registered Person must ensure the paving around the home is made level in order to prevent accidents. The Registered Person must ensure that the review of the quality of care resident surveys is finalised and implemented as soon as possible. Timescale for action 1st January 2006 1st January 2006 1st January 2006 2. 24 23 3. 39 24 4. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard 36 14 20 Good Practice Recommendations The Registered Person should ensure that continued efforts are made to provide staff who are able to drive the mini bus. The Registered Person should ensure that the needs of one resident in relation to taking part in activities and outings is reviewed and monitored. The Registered Person must ensure the temperature of G51-G01 S36906 Lodge Hill V231966 19-07-05 Stage 4.doc Version 1.40 Page 24 169 Lodge Hill 4. 5. 6. 7. 24 24 33 36 the room for the storage of medication is monitored an d action taken if it exceeds 25c. The Registered Person should ensure that the floor in the upstairs bathroom is refurbished as planned. The Registered Person should ensure that the flooding that occurs near the friont door is addressed. The Registered Person should ensure that the increasing needs of one residen are reviewed to ascertain whether additional staff hours are required to meet her needs. The Registered Person should ensure that all staff receive the minimum six sessions of formal supervision per year. 169 Lodge Hill G51-G01 S36906 Lodge Hill V231966 19-07-05 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection Address 1 Address 2 Address 3 Address 4 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 169 Lodge Hill G51-G01 S36906 Lodge Hill V231966 19-07-05 Stage 4.doc Version 1.40 Page 26 - 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. 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