Inspection on 26/09/05 for Queen Ann Lodge

This inspection was carried out on 26th September 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

Queen Ann Lodge 20/06/07

Queen Ann Lodge 27/02/06

Queen Ann Lodge 06/01/05

Queen Ann Lodge 09/06/04

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

CARE HOME ADULTS 18-65 Queen Ann Lodge 36 Old Park Road London N13 4RE Lead Inspector Tony Brennan Unannounced Inspection 26th September 2005 11:00 Queen Ann Lodge DS0000010703.V249435.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Queen Ann Lodge DS0000010703.V249435.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Queen Ann Lodge DS0000010703.V249435.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Queen Ann Lodge Address 36 Old Park Road London N13 4RE 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) 020 8882 2336 Mrs K B Kelly Ms Pamela Kelly Care Home 7 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (7) of places Queen Ann Lodge DS0000010703.V249435.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The number of service users that the home is able to accommodate is seven adults of either gender. Any resident accommodated in the second floor bedroom has no mobility impairment, including sensory impairment and does not require assistance in the event of evacuation of fire. The registered manager provides a copy of the registration certificate and these conditions to the London Fire & Emergency Planning Authority. The change in useable space in the first floor front bedroom is noted as being acceptable. 6th January 2005 Date of last inspection Brief Description of the Service: Queen Ann Lodge is registered to provide personal care for seven service users who have mental health problems. The home has been operating for almost two years and the proprietor also owns the premises next door, which is also a registered care home. The home has been well adapted for use as a care home. All service users have single rooms, some of which are very large. These are located on the ground and first floors. There is a recently added bedroom on the second floor that has en suite facilities. There are also well kept communal areas and a well maintained garden to the rear of the building. The home is in a residential area of Palmers Green and is close to local shops and businesses. The service aims to provide a supportive and enabling environment to people who have enduring mental health needs. There is a strong emphasis on promoting independence and helping service users establish and maintain family and community networks. Queen Ann Lodge DS0000010703.V249435.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken as part of the annual inspection process. The inspector also sought to confirm that the one area for improvement found at the last inspection was addressed. The inspection took place over one day. The registered person assisted the inspector. The inspector spoke with five service users and two staff. The inspector observed practice. The inspector toured the building and examined a range of records relating to the care and management of the home. What the service does well: 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. Queen Ann Lodge DS0000010703.V249435.R01.S.doc Version 5.0 Page 6 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 Queen Ann Lodge DS0000010703.V249435.R01.S.doc Version 5.0 Page 7 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): 23 Service users needs are assessed prior to admission to the home to ensure they receive the care and support they require. The home meets the assessed needs of service users. EVIDENCE: Service users said that staff understood how to meet their needs. Staff spoken to could explain how the needs of the service users were met. The inspector observed interaction between staff and service users. This was seen to be positive and supportive. One service user explained that staff had taken time to talk through his concerns with regard to a recent bereavement. The inspector found that there were detailed assessments of the service users needs. There were detailed assessments that outlined the mental health needs of people who use the service. The assessment had been used as the basis to develop care plans. Queen Ann Lodge DS0000010703.V249435.R01.S.doc Version 5.0 Page 8 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): 679 Care plans provided detailed information on how the needs of service users would be met. The service users were aware of the restrictions being placed on them. Risks to service users were assessed. EVIDENCE: Service users said that staff understood their needs. The care plans identified the actions required to meet the needs of the service users. The staff spoken to understood the needs of service users. Service users confirmed they had been consulted regarding the contents of their care plans. The inspector found that service users had signed to confirm they had been involved in the regular reviews of their care plans. Care plans were reviewed monthly through key worker meetings. Service users confirmed that they were consulted about and understood the restrictions placed on them. One service user mentioned that they only go out with a member of staff due to their needs. Risk assessments outlined the actions to be taken to prevent risks. The risk assessments were cross referenced to the care plans and were discussed in the daily notes. Queen Ann Lodge DS0000010703.V249435.R01.S.doc Version 5.0 Page 9 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): 11 12 16 17 Service users are supported to develop their daily living skills. Service users are supported to participate in activities of their choice. Service users are supported to determine their own routines and can choose to live the way they wish. Service users are provided with a choice of varied and balanced meals. EVIDENCE: The inspector observed that activities are taking place and service users confirmed that various activities had been offered. Service users spoke positively about a recent trip to Clacton on Sea. One service user said they have regular contact with the church and staff support their attendance. This was recorded in the relevant care plan. Other service users are attending day centres. The registered manager outlined a range of future events which service users are being supported to organise and to participate in. Service users also said that they had been involved in the planning, shopping and cooking of meals, and other domestic tasks. Their level of involvement was recorded in the care plans. The inspector observed one of the people who use the service washing up after lunch. Those who use the service said that they did not feel restricted and were encouraged to be as independent as possible. Service users confirmed that staff listen to them and support them to take Queen Ann Lodge DS0000010703.V249435.R01.S.doc Version 5.0 Page 10 decisions. Service users commented that the food was good and choices were provided. The menu showed that varied and balanced meals were offered. Service users said they were consulted about the choices being offered each week. The inspector saw that meals were well presented and they were provided in a relaxed environment. Queen Ann Lodge DS0000010703.V249435.R01.S.doc Version 5.0 Page 11 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 20 Service users have access to the medical care they need. Service users are protected by safe procedures for handling medication. EVIDENCE: Records seen showed that service users were receiving the medical care that they needed. Care plans outlined the medical needs of service users and the support they required. Mental health needs had been reviewed with relevant professionals. The medicine records for receiving, administering and return of medicines to the pharmacist were found to be complete. Medication profiles are up to date and record when medication had been reviewed. Service users said that they had been involved in the review of their medicines. Staff have undergone medicines training. The handling and recording of controlled medicines was complete. Queen Ann Lodge DS0000010703.V249435.R01.S.doc Version 5.0 Page 12 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): The service users are confident that their complaints will be listened to, taken seriously and acted upon. The service users are protected from abuse. EVIDENCE: Service users said that they felt confident in making their concerns known to staff. One service user said that they had raised an issue regarding the choice of food and this had been responded to positively. The complaints policy explained how to make a complaint and how it would be dealt with. The complaints record showed actions taken to resolve complaints. Service users said that they felt safe and could approach staff if there were any concerns regarding how they are treated. There were comprehensive policies on handling abuse and protection. Staff spoken to by the inspector were able to show that they understood issues to do with adult protection. Training had taken place on adult protection. Queen Ann Lodge DS0000010703.V249435.R01.S.doc Version 5.0 Page 13 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 Service users live in a homely environment that meets their needs. The home is clean and hygienic. EVIDENCE: All service users spoken to confirmed they here happy with the facilities offered by the home. The home was accessible and located close to shops, public transport and other community facilities. The inspector found that regular maintenance was taking place to ensure that the home was well furnished, decorated and safe. The inspector found that the home was clean and hygienic. Staff spoken to understood how to prevent cross infection and equipment was provided for this purpose. Queen Ann Lodge DS0000010703.V249435.R01.S.doc Version 5.0 Page 14 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 33 34 35 36 Staff do have all the skills to meet the needs of service users. There are sufficient staff to meet the needs of the service users. The service users are protected by the home’s recruitment procedures. Staff are appropriately supervised. EVIDENCE: Staff were observed working with the service users and were seen to be offering appropriate and sensitive support. Service users said that staff were supportive and helpful. The inspector saw that training records showed that the home had achieved the target of 50 of staff having NVQ in care. Service users said that they felt that there were sufficient staff to meet their needs. The rota showed that the staffing level was maintained at all times. The inspector examined three staff files and found that they contain all the required documentation relating to the recruitment of staff. The inspector saw records that confirmed that staff had gone through an appropriate induction. Records showed that staff had received all the required training. Training had also been provided on mental health and related topics. The home has been awarded the Investors in People Award. Monthly group supervision is taking place and this was being recorded. The inspector saw minutes of these meetings and staff were able to obtain copies. Queen Ann Lodge DS0000010703.V249435.R01.S.doc Version 5.0 Page 15 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): 41 42 Records are maintained to ensure the safety of service users. Service users and staff health and safety is promoted. EVIDENCE: The inspector found that all the records examined were clearly written and contained the necessary information. The inspector saw that the appropriate checks and drills were taking place to prevent fire. There were records that confirmed that the fire equipment had been maintained and the fire risk assessment was in place. Staff had the necessary health and safety training. The inspector saw that the first aid box contained all the required items. The required certificates for gas and electrical safety were in place. Staff spoken to understood the procedures relating to safety. There were general risk assessments of all working practices in place. Queen Ann Lodge DS0000010703.V249435.R01.S.doc Version 5.0 Page 16 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 X 3 3 X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X 3 LIFESTYLES Standard No Score 11 3 12 3 13 X 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 3 3 4 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Queen Ann Lodge Score X 3 3 X Standard No 37 38 39 40 41 42 43 Score X X X X 3 3 X DS0000010703.V249435.R01.S.doc Version 5.0 Page 17 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 Queen Ann Lodge DS0000010703.V249435.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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