Inspection on 10/02/06 for Lucerne House (21-23)

This inspection was carried out on 10th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 but made no statutory requirements on the home.

Other inspections for this house

Lucerne House (21-23) 13/10/09

Lucerne House (21-23) 22/04/08

Lucerne House (21-23) 23/05/07

Lucerne House (21-23) 08/05/06

Lucerne House (21-23) 01/11/05

Lucerne House (21-23) 10/03/05

Lucerne House (21-23) 28/07/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

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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 Lucerne House (21-23) 21-23 Lucerne Road Thornton Heath Croydon Surrey CR7 7BB Lead Inspector James Pitts Unannounced Inspection 10th February 2006 14:05 Lucerne House (21-23) DS0000025808.V277865.R01.S.doc Version 5.1 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 Lucerne House (21-23) DS0000025808.V277865.R01.S.doc Version 5.1 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. Lucerne House (21-23) DS0000025808.V277865.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Lucerne House (21-23) Address 21-23 Lucerne Road Thornton Heath Croydon Surrey CR7 7BB 0208 239 9547 0208 239 9547 NO EMAIL 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) Mrs Naomi Wallen Mr Wayne Wallen Mrs Naomi Wallen Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Lucerne House (21-23) DS0000025808.V277865.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st November 2005 Brief Description of the Service: 21 and 23 Lucerne Road were two terraced houses, which have been joined by means of walkways on the ground and first floors. Having applied two years ago to run the two establishments as one home, the Registered Providers are registered as a single home accommodating up to a maximum of six adults with learning disabilities. At the time of inspection the home had one vacancy as a service user moved out earlier this year. The home is close to the town centre and accessible public transport. Lucerne House (21-23) DS0000025808.V277865.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on a Friday afternoon and two service users and an employed member of staff were present. One of the joint proprietors, Mr Wallen, arrived during the course of this visit. One of the service users spoke at length about their past life history and the things that they enjoy doing. As Mrs Wallen, the other joint owner and also the manager was not present during the first visit. Two further unannounced visits were carried out although no-one was at home on these occasions. For that reason, some of the requirements in this report could not be directly verified. They are therefore repeated along with an expectation that the manager must confirm and provide evidence of what has been done to achieve them. The standard of direct care remains good and improvements to the way in which care planning takes place continues to be a positive sign. The service users are cared for by people who do have a genuine regard for their well being; however, aspects of professional management of the home do still require improvement. The manager has previously commented on the difficulties she has had with running a care home and undertaking the training in management that she requires. Again there have been improvements in the last year but the progress remains slow and the areas that are referred to again in this report must be addressed without any further and entirely unnecessary delay. What the service does well: The home is good at ensuring that service users are supported appropriately in all aspects of their day-to-day living, not least with their general health and personal care. This also includes providing the necessary support to service users that will enable them to be a part of the wider community and to have aspirations, expectations and goals. The staff team is good at encouraging service users to maintain family relationships and friendships. The home is comfortable and is a safe place in which to live. Lucerne House (21-23) DS0000025808.V277865.R01.S.doc Version 5.1 Page 6 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. Lucerne House (21-23) DS0000025808.V277865.R01.S.doc Version 5.1 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 Lucerne House (21-23) DS0000025808.V277865.R01.S.doc Version 5.1 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): 2 Standard 2 was assessed as being met at the previous inspection and it was, therefore, not looked at during this visit. EVIDENCE: Lucerne House (21-23) DS0000025808.V277865.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7, 8, 9 & 10 The service users can still feel confident that staff generally know what they need. The home still needs to establish a keyworker system to further support this work. However, the service users can be assured that the staff will try their best to make sure that each person who lives at the home is allowed to live the sort of life that they choose. The only continuing risk to this happening well is that staff still do need to get better at making sure that risk assessments properly reflect their needs. EVIDENCE: Each service user has an individual care plan. These plans were amended further last year and are more informative in terms of their details, aims, and objectives and how these will be achieved. The manager introduced a person centred planning format, to ensure that care plans properly reflect the support that is required for each service user, and evidence that they are involved in compiling their own care plan. A keyworker system is still not in operation and one should still be established to provide focus on service user progress and support needs. A keyworker is a member of staff who especially makes sure that the service user is being supported in the right way. Lucerne House (21-23) DS0000025808.V277865.R01.S.doc Version 5.1 Page 10 As referred to at the previous inspection, the service users and usually Mrs Wallen as the manager get together for a house meeting, each month. At this meeting everyone should talk about what it is like to live at the home and about anything that has changed or needs to get better. This meeting is somewhere that everyone can also say how they are feeling about living together and to ask for the things that they want. The minutes of these meetings are still brief and could still be better at reflecting the things that service users say and what choices they are offered about the things that happen in the home. As referred to at the previous inspection, the home compiles a risk assessment for each of the service users. A risk assessment tells the staff how to make sure that each of the service users is kept safe from anything that might harm them. The staff are still very good at doing this about very particular needs for each of the people who live here but they must also still write risk assessments for more general areas of safety, for example if it is safe for particular service users to go out alone. They must then make sure that the risk assessments are looked at very regularly to make sure that these are changed if they need to be. The staff are still very good at making sure that nobody is told anything about any of the service users unless the person is allowed to know. The staff are also very good at making sure that they tell the right people about things that are happening to the people who live here. But they only tell those people that are allowed to know. The home has a confidentiality policy that tells staff about how to make sure that they keep to this. However, as referred to at the previous inspection, there should still be an access to files policy that can tell the service users how they may see what is written about them and have this explained to them if they need it to be. Lucerne House (21-23) DS0000025808.V277865.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All of the above standards were assessed as being met at the previous inspection and so they were not looked at again during this visit. EVIDENCE: Lucerne House (21-23) DS0000025808.V277865.R01.S.doc Version 5.1 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All of the above standards were assessed as being met at the previous inspection and so they were not looked at again during this visit. EVIDENCE: Lucerne House (21-23) DS0000025808.V277865.R01.S.doc Version 5.1 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 The service users can continue to feel confident that the staff team at the home know what to do if there are complaints or concerns about abuse. The home has clear guidance for staff about the procedures to be followed in either of these circumstances. EVIDENCE: The service users are given clear information about how to complain and what happens when they make a complaint. No complaints have been made to either the home or to the Commission since the previous inspection visit. The staff continue to be good at making sure that all of the service users are protected from abuse (this means that the staff at the home do everything that they can to stop any of the service users from being hurt by someone else). There is also clear written information for staff about what to do if they think that a service user is being hurt or abused by another person. The staff know what they then have to do to keep people safe. The home has a whistle blowing policy, and also one dealing with bullying or harassment, although this still only refers to staff and must be expanded to refer to service users. There was again still no evidence of all staff having read any of these policies this must be remedied without further unnecessary delay. Lucerne House (21-23) DS0000025808.V277865.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 The service users can continue to feel confident that they are living in a well maintained and clean home. EVIDENCE: The home continues to be comfortable and the staff do the right things to make sure that the house is generally a safe place for the service users to live. Some areas of the home were showing signs of wear at the previous inspection visit, however, the owners recognised this and included areas of refurbishment that need to be done as a part of their annual development plan. Some refurbishment was underway at the time of this visit. The house is kept very clean and is free of any unpleasant odours. Lucerne House (21-23) DS0000025808.V277865.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 34 & 36 Service users still cannot feel confident that there is a proper procedure for recruiting staff who are safe people to support them. The quality of the support that is offered by the staff team could still be compromised if staff are not supervised properly. EVIDENCE: All but one of the staff has been employed within the home for some time, and all have job descriptions. A copy of the General Social Care council code of practice must still be obtained and be issued to staff at the home. The home recruited a new member of staff to work part time last year. However, as reported at the previous inspection, it is of serious concern that the proper background checks were not completed before this person started working here. There were no references and no CRB check, although the manager was able to show at the time that this was being chased up. The owners / manager must ensure that they adhere to proper recruitment procedures and must still take up the references for the person they employed. The manager was informed at the previous inspection that once this had been done she must write to the Commission to confirm that the \CRB and Lucerne House (21-23) DS0000025808.V277865.R01.S.doc Version 5.1 Page 16 references have been obtained. There has been no progress on this since the previous inspection. The home is still not able to evidence that staff receive any form of formal supervision (this is a time that each member of staff spends talking about how they are getting along in their work). This must be implemented and additionally the manager must attend training in order to gain an awareness of the purpose and function of the professional supervision of staff in a care setting. Lucerne House (21-23) DS0000025808.V277865.R01.S.doc Version 5.1 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, & 40 The service users cannot feel confident that they are living in a home that properly considers the need for diligent management. However, the can feel confident that most of the necessary health and safety checks are properly carried out. EVIDENCE: Mrs Wallen, who is also the manager, said at the previous inspection that she was planning to start the NVQ level 4 in January 2006 at a nearby college. She must now confirm with the Commission in writing if she has commenced this course. The home has been told at previous inspections that they must introduce a quality assurance system, although an annual development plan is written. The manager must confirm in writing with the Commission whether a quality assurance system has been established, as this remains an unmet requirement from previous inspections. Lucerne House (21-23) DS0000025808.V277865.R01.S.doc Version 5.1 Page 18 The home has in place a comprehensive selection of policies and procedures covering most of the topics set out in Appendix 3 of the National Minimum Standards for Care Homes for Adults. The manager has previously said that she is aware that an Individual Planning and review policy still needs to be put in place, as well as a Staff smoking policy and a racial harassment policy. The home manager must still also expand the volunteer policy to refer to the need for prospective volunteers to undergo criminal record (CRB) and protection of vulnerable adults (POVA) checks. The policies and procedures must still be dated and reviewed regularly. Staff have access to the homes policies and procedures which they should still sign and date as poof that they have read and understood any new or revised policies and procedures. Lucerne House (21-23) DS0000025808.V277865.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME 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 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 1 32 3 33 X 34 1 35 x 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 1 1 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X x 1 X 1 1 x x x Lucerne House (21-23) DS0000025808.V277865.R01.S.doc Version 5.1 Page 20 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA8 Regulation 4(1)(c) Sch. 1(10) Requirement Consultation with service users must still be in greater evidence and show that the home is taking their views and preferences into account (this requirement remains outstanding from the two previous inspections although some signs of improvement were noted) Risk assessments must be more detailed and outline the nature of any perceived risk, and must be updated at regular intervals. (this requirement remains outstanding from the two previous inspections and must be attended to immediately) Timescale for action 10/02/06 2. YA9 13(4)(b) 10/02/06 3. YA23 13 (6) The bullying and / or harassment 10/02/06 policy must be expanded to also refer to service users. 4. YA31 18 ( c ) (i) A copy of the General Social 10/02/06 Care council code of practice must be obtained and be issued to all staff at the home (this requirement remains outstanding from the previous inspection and must be attended to DS0000025808.V277865.R01.S.doc Version 5.1 Page 21 Lucerne House (21-23) immediately). 5. YA34 19(a) &(b)(i) &5(d) 19(5)(b) The manager must write to the 10/02/06 Commission to confirm that the \CRB and references have been obtained for the newly appointed member of staff and these All staff must receive a minimum 10/02/06 of six supervision sessions per year, which are recorded. (this requirement remains outstanding from the previous inspection although it could not be verified at this visit as the manager was not available, but must now confirm in writing with the Commission that this has been actioned) 10/02/06 The manager must commence the NVQ level 4 qualification without further delay. (this requirement remains outstanding from the previous inspection although it could not be verified at this visit as the manager was not available, but must now confirm in writing with the Commission that this has been actioned) The Registered Providers must 10/02/06 develop quality assurance tools, which are designed to obtain the views of service users families (this requirement remains outstanding from the two previous inspections and a copy of this quality assurance tool must immediately be sent to the Commission). The home manager must expand the volunteer policy to refer to the need for prospective volunteers to undergo criminal record (CRB) and protection of vulnerable adults (POVA) checks. The policies and procedures DS0000025808.V277865.R01.S.doc 6. YA36 7. YA37 9 (2) (b) (i) 8. YA39 24(3) 9. YA40 NMS Appendix 3 10/02/06 Lucerne House (21-23) Version 5.1 Page 22 must still be dated and reviewed regularly. (this requirement remains outstanding from the previous inspection and a copy of this policy must immediately be sent to the Commission). 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. Refer to Standard YA6 YA10 Good Practice Recommendations A keyworker system should still be established to provide focus on service user progress and support needs. An access to files policy should be established. The aim of this policy should be to enable service users to have reasonable access to information that is held about them by the home, and to restrict access to particular third parties without the express consent of the service user. Staff have access to the homes policies and procedures, which they should sign and date as poof that they, have read and understood any new or revised policies and procedures. 3. YA40 Lucerne House (21-23) DS0000025808.V277865.R01.S.doc Version 5.1 Page 23 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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