Inspection on 23/02/06 for Priory Lodge

This inspection was carried out on 23rd February 2006.

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

Priory Lodge 13/04/07

Priory Lodge 15/12/04

Priory Lodge 18/03/04

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

CARE HOME ADULTS 18-65 Priory Lodge 62 Priory Street Colchester Essex CO1 2QE Lead Inspector Jane Greaves Unannounced Inspection 23rd February 2006 13:00h Priory Lodge DS0000017913.V282725.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 Priory Lodge DS0000017913.V282725.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. Priory Lodge DS0000017913.V282725.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Priory Lodge Address 62 Priory Street Colchester Essex CO1 2QE 01206 797243 01206 790756 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) Mr David Krishnalall Jangali Jeanette Irvine Care Home 20 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (20) of places Priory Lodge DS0000017913.V282725.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, under the age of 65 years, who require care by reason of a mental disorder, excluding learning disability or dementia (not to exceed 20 persons) 5th September 2005 Date of last inspection Brief Description of the Service: Priory Lodge is a purpose build residential unit for individuals who have mental health problems. There are 20 places for people aged 18-65 years old. Priory Lodge is based in a residential street in the centre of Colchester within walking distance of all amenities. Priory Lodge DS0000017913.V282725.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This routine unannounced inspection took place on 23rd February over 4 hours. The inspection included taking a tour of the premises, scrutiny of records, discussions with residents, staff members and the management team, and a postal survey of relatives’ views. 12 of the 43 National Minimum Standards were assessed at this inspection with all being met and two being exceeded. The standard of care observed at Priory Lodge was good and no areas of concern were identified at this inspection visit. The home had a warm and inclusive family atmosphere. The inspector appreciated the welcome and co-operation received with the inspection process from all parties concerned. What the service does well: What has improved since the last inspection? The previous inspection visit did not raise any legal requirements or good practice recommendations. Priory Lodge DS0000017913.V282725.R01.S.doc Version 5.1 Page 6 Since the previous inspection some residents’ rooms and communal areas had been redecorated and re-carpeted. 5 residents’ bedrooms contained new furniture. Sky television had been installed for the residents’ entertainment giving greater access to view films, music and sporting events. A fountain had been purchased for the communal garden and will be installed by the summer. A snooker table had been installed in the rear conservatory for the residents recreation and a new DVD player had been purchased. 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. Priory Lodge DS0000017913.V282725.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 Priory Lodge DS0000017913.V282725.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): 1 • Prospective residents had the information they needed to make an informed choice about where to live. EVIDENCE: The home’s Statement of Purpose and Service User Guide had been recently reviewed and revised to reflect the current ethos, aims, objectives, staffing levels and management structure within the home. These documents were comprehensive and clear and contained all information required by Regulation 4 Schedule 1 of the Care Homes Regulations 2001. It was noted that the information contained within these documents accurately reflected the environment, staffing structure, services provided and general philosophy of the home ensuring that prospective residents had appropriate information to make an informed choice about where to live. Priory Lodge DS0000017913.V282725.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): 9 • Residents were supported to take risks as part of an independent lifestyle. EVIDENCE: Risk assessments were included in residents’ care plans. Assessments were made before admitting a new resident into the home and were recorded appropriately with evidence of input from the resident/representative. Regular reviews were documented and corresponding changes made to the care plans to reduce or minimise identified risks or hazards to residents’ personal safety and well being. Where the management strategy to minimise a risk to a resident resulted in an infringement of the individual’s rights this was appropriately documented with evidence of the resident/representatives participation in the decision making processes. Residents were provided with training regarding their personal safety. It was discussed at the inspection how the management team encouraged residents to take part in regular fire drills. Priory Lodge DS0000017913.V282725.R01.S.doc Version 5.1 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13 and 16 • • Residents were supported to be part of the local community. Residents’ rights were respected and responsibilities recognised in their daily lives. EVIDENCE: Some residents at Priory Lodge were able and encouraged to access the local community independently. The registered manager reported her disappointment that some community mental health day centre places had been withdrawn due to staff shortages at the centres or insufficient funding whilst other centres had long waiting lists. Evidence was available to demonstrate the registered person’s persistence in pursuing these services for the residents. This had been an on going issue over the previous two inspections; Social workers and the Community Mental Health Teams had been informed. Residents spoke happily about their lives in the community, attending church, visiting pubs and shopping. Priory Lodge DS0000017913.V282725.R01.S.doc Version 5.1 Page 11 The only ‘house rules’ for the residents of Priory Lodge were that smoking was restricted to a specific area, that residents informed a staff member when leaving the premises and everyone deserved respect. Staff members were seen to speak to residents in a warm and respectful manner. Some residents were able to be involved in the daily tasks of running the home, one resident reported that they were able to be more independent now as a result of the encouragement received from staff. Residents had unrestricted access to the house and the grounds. Priory Lodge DS0000017913.V282725.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): 19 • Residents’ physical and emotional needs were met. EVIDENCE: Evidence was available on file to demonstrate the health needs, both physical and emotional, of the residents were being met. Care plans provided clear and comprehensive information regarding the residents’ healthcare needs. Initial assessments plus subsequent reviews and corresponding changes to the care plan were included. Records were present to evidence healthcare interventions and any resulting actions to be taken by care staff. The registered manager had initiated a system of supervision with residents. This took the form of relaxed one to one sessions with individuals to discuss any issues they chose to. The registered manager was well known and respected by the residents and spoke and consulted with them on a daily basis but felt this special one to one time would be beneficial for the residents’ emotional and psychological well being. Priory Lodge DS0000017913.V282725.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 • Residents could be confident their views were listened to and acted upon. EVIDENCE: The home had received three complaints since the previous inspection. All had been responded to in a timely manner and non were substantiated. The home’s complaints policy and procedures were included in the services Statement of Purpose and the service User Guide and these included contact details for the Commission for Social Care Inspection. Discussions with residents confirmed they were aware of whom to complain to and reported they would be confident to make a complaint if they had occasion to. The home’s compliment folder contained many positive and warm endorsements from family members, representatives and professionals regarding the care and professionalism provided by the team at Priory Lodge. Priory Lodge DS0000017913.V282725.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): 28 • Shared spaces complemented and supplemented residents’ individual rooms. EVIDENCE: There was an on going redecoration program at Priory lodge. All communal spaces were warm, and decorated and furnished to a good standard. All the residents spoken with made positive comments regarding the environment they lived in. A snooker table had been installed in the rear lounge for residents use and sky television had been installed. Priory Lodge DS0000017913.V282725.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): 34 and 35 • • Residents were supported and protected by the home’s recruitment policies and procedures. Appropriately trained and competent staff members met residents’ individual and joint needs in a caring and professional manner. EVIDENCE: Staff files sampled at this inspection demonstrated the home’s recruitment policies and procedures were being adhered to. No new staff started to work at the home until all the relevant checks had been undertaken. The registered manager reported that the residents were actively involved in the selection of new staff. This was evidenced through conversation with one resident. The registered manager was able to demonstrate the home’s training plan was up to date and included all mandatory training requirements plus service specific training such as epilepsy awareness. Refresher courses had been planned and budgeted for and in some cases booked. Priory Lodge DS0000017913.V282725.R01.S.doc Version 5.1 Page 16 Each staff member had an individual training and development plan and maintained copies of all their certificates. The registered manager had provided staff with a filing cabinet to stored their individual training information in order to be accessed as and when required. Staff spoke highly of the training opportunities provided for them at Priory Lodge. One staff member reported how useful the bereavement awareness course had been not only from a work perspective but also on a personal level too. The home has exceeded the requirement for 50 of care staff to hold NVQ 2 and some of these were now working towards the NVQ 3 qualification. Priory Lodge DS0000017913.V282725.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, 38 and 42 • • • Residents benefited from a well run home. Residents benefited from the ethos, leadership and management of the home. The health safety and welfare of residents was promoted and protected. EVIDENCE: The registered manager had registered and paid for the NVQ level 4 qualification however had not yet received a start date for the course. The registered manager confidently predicted that this qualification would be achieved by year end. The registered manager was committed to ensuring the aims and objectives of the home were achieved. The relatives survey responses and discussions with Priory Lodge DS0000017913.V282725.R01.S.doc Version 5.1 Page 18 residents and staff confirmed that the ethos of the home is that promised in the home’s Service User Guide and Statement of Purpose. The home complied with the Care Standards act and Regulations and other legal requirements. The registered manager undertook mandatory training alongside the staff team as well as more role specific training such as a Health and Safety manager’s Workshop attended recently. There were clear lines of accountability within the staff team. All staff and residents spoken with were aware of each other’s roles and responsibilities. The registered manager should be commended for her commitment to the staff training and development program and her overall dedication to the development of this service for the benefit of the residents. Complete comprehensive environmental risk assessments took place fortnightly. One staff member had embraced this task enthusiastically and had involved the remaining staff team to recognise risks and hazards. Evidence showed where risks had been identified there was a corresponding report made to the registered manager and an interim action plan to minimise the risk before professional services could be obtained. The registered manager’s logbook contained the entry of the risk notification, the repairs required and when they took place. Required Health and safety records all present and were maintained in a clear and accessible manner. The home had 6 appointed 1st Aiders on the staff team and all staff had received training in basic Food Hygiene and Infection Control. The registered manager was able to demonstrate that all annual safety checks had taken place. A list of portable electrical appliances owned by individual residents was available including evidence of regular checks. If an appliance had been condemned this was recorded clearly. Evidence was available to confirm regular visits from the Fire department and the Health and Safety Executive. Any accidents, injuries or incidents of illness or death were recorded appropriately and the Commission for Social Care Inspection was informed under regulation 37. Priory Lodge DS0000017913.V282725.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 3 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 X ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 3 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 X 34 3 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X 3 X LIFESTYLES Standard No Score 11 X 12 X 13 3 14 X 15 X 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 X X 3 4 X X X 3 X Priory Lodge DS0000017913.V282725.R01.S.doc Version 5.1 Page 20 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. Standard Regulation Requirement Timescale for action 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 Priory Lodge DS0000017913.V282725.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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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