Inspection on 08/05/06 for Lucerne House (21-23)

This inspection was carried out on 8th May 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 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

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) 10/02/06

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

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 Lucerne House (21-23) 21-23 Lucerne Road Thornton Heath Croydon Surrey CR7 7BB Lead Inspector James Pitts Key Unannounced Inspection 8th May 2006 10:50 Lucerne House (21-23) DS0000025808.V291263.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.V291263.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.V291263.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.V291263.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th February 2006 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.V291263.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 Monday morning although all of the service users were out at that time. Questionnaires were left for the service users to complete at a later date if they wish too although service users will be seen at the next inspection visit so that they can provide their views about the home at that time. Both of the joint proprietors, Mr & Mrs Wallen, were present and the one member of staff who is employed arrived a little later. 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 some further continuing improvements in the last three months since the previous unannounced inspection and it is expected that the training in management that Mrs Wallen is soon to start may well provide her with the necessary skills to fulfil the remaining requirements that are contained in this report. What the service does well: What has improved since the last inspection? The bullying and / or harassment policy has been expanded upon and now also refers to service users. Policies and procedures are also now being read by staff who sign to confirm that they have done so. Mrs Wallen has provided written evidence that she is registered with a training company to commence the NVQ level 4 qualification and is awaiting a start date. Lucerne House (21-23) DS0000025808.V291263.R01.S.doc Version 5.1 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. Lucerne House (21-23) DS0000025808.V291263.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.V291263.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 key standards inspection and as no new service users have come to live at the home since that time this standard could not be assessed at this visit. This standard will not be assessed again until such time as any new service users come to live at the home. EVIDENCE: Lucerne House (21-23) DS0000025808.V291263.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): 7, 8, 9 & 10 The service users can still feel confident that staff generally know what they need. The home has now established a keyworker system to further support this work.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: A keyworker system is now in operation as was recommende4d at the previous unannounced inspection. A keyworker is a member of staff who especially makes sure that individual service users are being supported in the right way. 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. At the previous unannounced inspection it was noted that the minutes of these Lucerne House (21-23) DS0000025808.V291263.R01.S.doc Version 5.1 Page 10 meetings are 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. The minutes of meetings since then were not available to see during this visit as a member of staff had them in order to type up the minutes to put into a folder. The requirement that was made previously will remain in this report and will be looked at again at the next visit. 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. There has been some improvement and this was discussed again during this visit and further advice was provided to the manager on the areas that could be included in the risk assessments. 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 previous inspections, 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.V291263.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): None of the above standards were looked at during this visit, although it should still be noted that at the previous key standards inspection all of the key areas were seen to be achieved. EVIDENCE: Lucerne House (21-23) DS0000025808.V291263.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): 21 The service users can feel confident that the home is able to properly consider the needs of people who are ageing. EVIDENCE: One of the service users has recently reached the age of 65. The manager is aware that a variation request needs to be submitted to the Commission about to allow this person to remain at the home. The service user in question is still happy to remain living here, the home is still able to safely care for this person and they are still easily able to move about the house and use all of the facilities. In these circumstances the variation request should not prove difficult for the Commission to agree to. Lucerne House (21-23) DS0000025808.V291263.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, which now also refers to service users. There is also now evidence that staff have read these policies. There have been no reported concerns about any of the service users having been harmed. Lucerne House (21-23) DS0000025808.V291263.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 are completing areas of refurbishment that need to be done as a part of their annual development plan. A refurbished and larger lounge has been created at the rear of the house. The house is kept very clean and is free of any unpleasant odours. Lucerne House (21-23) DS0000025808.V291263.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): 32, 34 & 36 Service users can feel more confident that there is improvement to the procedure for recruiting staff that 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: 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, it was as reported at the previous inspection that it was of serious concern that the proper background checks had not been completed before this person started working here. There were no references and no CRB check. This has now been rectified and references and a CRB check have been obtained and these were looked at during this visit. The home is able to provide some evidence that staff receive formal supervision (this is a time that each member of staff spends talking about how they are getting along in their work). This must still be at least six times each year and the manager was given further advice on what topics each staff supervision should cover. Lucerne House (21-23) DS0000025808.V291263.R01.S.doc Version 5.1 Page 16 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 still cannot feel entirely confident that they are living in a home that properly considers the need for diligent management. 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 was able to confirm during this visit that she is registered to commence a course with an independent training company and is awaiting a start date from them. . The home has been told at previous inspections that they must introduce a quality assurance system, although an annual development plan is written. This was discussed again during this visit and further advice was provided about what a quality assurance system should cover and how it should be implemented. This remains an unmet requirement from previous inspections. Lucerne House (21-23) DS0000025808.V291263.R01.S.doc Version 5.1 Page 17 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 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 that they now sign and date as proof that they have read and understood any new or revised policies and procedures. Lucerne House (21-23) DS0000025808.V291263.R01.S.doc Version 5.1 Page 18 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 x 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 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 x 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 X 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 3 1 X 1 1 X X x Lucerne House (21-23) DS0000025808.V291263.R01.S.doc Version 5.1 Page 19 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 08/05/06 2. YA9 13(4)(b) 08/05/06 3. YA31 18 ( c ) (i) A copy of the General Social 08/05/06 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 immediately). Lucerne House (21-23) DS0000025808.V291263.R01.S.doc Version 5.1 Page 20 4. YA36 19(5)(b) All staff must receive a minimum 08/05/06 of six supervision sessions per year, which are recorded. (This requirement remains outstanding from previous inspections). The Registered Providers must develop quality assurance tools, which are designed to obtain the views of service users families (this requirement remains outstanding from the two previous inspections). 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 must still be dated and reviewed regularly. (This requirement remains outstanding from previous inspections). 08/05/06 5. YA39 24(3) 6. YA40 NMS Appendix 3 08/05/06 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. Refer to Standard YA10 Good Practice Recommendations 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. Lucerne House (21-23) DS0000025808.V291263.R01.S.doc Version 5.1 Page 21 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. Extracts may not be used or reproduced without the express permission of CSCI Lucerne House (21-23) DS0000025808.V291263.R01.S.doc Version 5.1 Page 22 - 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. 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