Inspection on 12/12/05 for Queens Lodge

This inspection was carried out on 12th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Queens Lodge 07/02/08

Queens Lodge 14/06/06

Queens Lodge 30/08/05

Queens Lodge 07/12/04

Queens Lodge 23/04/04

Queens Lodge 11/07/02

Similar services:

Insight - Eastchurch

Southfields

Thorndene

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Queens Lodge 4 Goffs Park Southgate Crawley West Sussex RH10 6AX Lead Inspector Mrs S Rodgers Unannounced Inspection 12th December 2005 15:00 Queens Lodge DS0000014675.V265063.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 Queens Lodge DS0000014675.V265063.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. Queens Lodge DS0000014675.V265063.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Queens Lodge Address 4 Goffs Park Southgate Crawley West Sussex RH10 6AX 01293 510734 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) Outreach 3 Way Mrs Margaret Lucas Care Home 23 Category(ies) of Learning disability (13), Learning disability over registration, with number 65 years of age (10) of places Queens Lodge DS0000014675.V265063.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. Only service users over the age of 65 years to be admitted to South View. Total number of service users not to exceed 23. That after the admission of the initial Service User Group no further persons under the age of 65 years will be admitted to South View. A maximum of 13 service users may be accommodated in Queens Lodge House. Only service users under the age of 65 years to be admitted to Queens Lodge House. A maximum of 10 service users may be accommodated in South View. Date of last inspection 30th August 2005 Brief Description of the Service: Queens Lodge is a care home, registered to provide care (PC) for up to twenty-three people in the Category LD, Learning Disability, including up to ten people over the age of sixty five. The property is purpose built and is situated near to Crawley town centre. The home consists of two buildings; Queens Lodge provides short stay accommodation for up to thirteen people with a learning disability and Southview which provides accommodation for up to ten people over the age of sixty five with a learning disability. In both buildings accommodation is provided on ground and first floor level. All bedroom accommodation is for single occupancy. There are lounge and dining facilities in both buildings. Outreach 3 Way is a charitable trust. the responsible individual on behalf of the trust is Mrs Vaneesa Keen. The post of registered manger is a shared post Mrs Margaret Lucus has responsibility for managing the site known as Queens Lodge and Mrs Kathleen Philpott has responsibility for manageing the site known as Southview. Queens Lodge DS0000014675.V265063.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 4 hours and was carried out as part of the routine programme of inspections. Preparation for this inspection focused the review of previous inspection reports and general correspondence. There has been one Adult Protection referral made by the management of the home. Appropriate procedures were followed and the Commission was informed with in the specified timescales as indicated in the Care Home Regulations 2001, Regulation 37. During the course of the inspection the inspector toured the home, spoke with residents within the communal areas of the home in order to gain a sense of how the home is being run and how they experienced staying/living at Queens Lodge and Southview. Staff were spoken with in order to gain a sense of the support and training they receive in order to carry out their jobs and to gain insight into how their knowledge of the aims and objectives of the homes philosophy of care. Due to the diverse needs of the residents not all were able to express their views however, residents who were able to communicate with the inspector indicated that they are happy when they visit Queens Lodge for a short stay they said comments like “ I can still go to day centre and music lessons”. Those living at Southview also told the inspector that they are happy living at the home. The inspector was able to observe the interactions between residents and staff, both were relaxed and confident in each other’s company. The inspector also noted that residents are enabled to access the local community on an individual basis, i.e. going to the local shops with staff. All staff spoken with were knowledgeable with regards the care needs of residents. It was clear that they were aware of the homes philosophy of care i.e. to support resident to lead an independent life within their individual capabilities. They confirmed that they feel supported by the management of the organisation and that they are encouraged and supported undertake training. The one requirement identified at the last inspection has been met in part, therefore remains as a requirement and one further requirement has been identified. The management is required to confirm in writing by the 27 January 2006 what action is being taken and the timescales by which compliance with the regulations will be met. Where standards have not changed from the previous inspections this report records that the findings were the same. Queens Lodge DS0000014675.V265063.R01.S.doc Version 5.0 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Although care plans have improved since the last inspection guidelines to address individual care needs must be in place. Develop a system to ensure that the home can demonstrate that all staff have received fire safety instruction. Queens Lodge DS0000014675.V265063.R01.S.doc Version 5.0 Page 7 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. Queens Lodge DS0000014675.V265063.R01.S.doc Version 5.0 Page 8 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 Queens Lodge DS0000014675.V265063.R01.S.doc Version 5.0 Page 9 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): These standards were not assessed at this inspection as they were met in full at the previous inspection visit. EVIDENCE: Queens Lodge DS0000014675.V265063.R01.S.doc Version 5.0 Page 10 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): 6,9 Care plans do not fully document how the needs of residents will be met. Residents are supported to take risks. EVIDENCE: Care plans seen at Queens Lodge identifies individual care need however, they do not fully record how those needs will be met. As discussed with Mrs Lucus the plan refers to guidelines on how to met need however, there were no guidelines in place. Risk assessments demonstrate that residents are enabled to take risks in order to develop and maintain an individual lifestyle. Residents preferences regarding activities or lifestyle choices are discussed, arrangements are made for them to undertake the activity, which is then monitored regularly to ensure that the expectations and needs of residents are being met. Queens Lodge DS0000014675.V265063.R01.S.doc Version 5.0 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): 15, 16 Residents are enabled to maintain contact with family and friends. Resident’s rights are respected. EVIDENCE: The homes Statement of Purpose clearly advises residents and their relatives of the home policy on maintaining contact with family and friends. One resident who were spoken with confirmed that she is supported and assisted to telephone their relatives regularly. Mrs Philpot advised the inspector that staff assist residents with correspondence i.e. writing letters, birthday and Christmas cards. Should a resident wish to develop a personal relationship they would be supported to do so. The Community Psychiatric Nurse would be contacted and discussions would take place with the resident with regards relationships, the body and contraception. Queens Lodge DS0000014675.V265063.R01.S.doc Version 5.0 Page 12 The inspector noted that staff respected that residents have rights, resident’s views were heard to be sought and permission to enter bedrooms was asked prior to the inspector touring the home. Records of meals provided indicated that a balanced diet is offered. The chef cooks meals in both units. Southview residents have their main meal at lunchtime as they do not generally go out to day centres and Queens Lodge residents have their main meal in the evenings. The chef regularly seeks the view of residents in order to develop menus in line with their preferred choices. Resident spoken with told the inspector “they liked the food and that they get enough to eat”. Queens Lodge DS0000014675.V265063.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 Appropriate systems are in place for dealing with medicines. EVIDENCE: The home has a pharmacy agreement with a local chemist. All staff who administer medication have had training provided by the local college. Records seen of the receipt, recording, storage, handling, administration and disposal of medication were in good order. Residents who stay at Queens Lodge take in their own medication. This is recorded on their medication sheet using information from the dispensing label. When residents return home any unused medication is returned. Queens Lodge DS0000014675.V265063.R01.S.doc Version 5.0 Page 14 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 A complaints procedure is in place. EVIDENCE: The homes complaints procedure clearly advises residents and/or their relatives of their right to complain. The procedure states each state of the complaint process and timescales by which the complaint will be dealt with. Residents spoken with told the inspector that they felt able to talk with all staff about any concerns that they may have. Queens Lodge DS0000014675.V265063.R01.S.doc Version 5.0 Page 15 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): 26,27 Private accommodation is appropriate to the needs of residents. Bathing and toilet facilities are appropriate to the needs of residents. EVIDENCE: From touring the home the inspector was able to determine that residents private accommodation was suitable to their needs and enabled them to maintain a level of independence. Residents furnish their rooms with their own belongings such as TV’s and radios and are able to use their rooms as they wish. Bathing and toilet facilities are provided in sufficient numbers to meet the needs of the current residents. Disabled bathing and toilet facilities are available. Queens Lodge DS0000014675.V265063.R01.S.doc Version 5.0 Page 16 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 Residents are supported by competent staff. Staff were relaxed, confident and knowledgeable with regards the needs of residents. EVIDENCE: Duty rotas indicate that staff are on duty in sufficient numbers and with the appropriate skill mix i.e. inexperienced staff are not on duty together without the support of experienced staff. All new staff receive induction training and then progress to the foundation course. Staff are encouraged and supported to undertake NVQ Awards specific the needs of the current residents, the Learning Disability Award Framework. Staff spoke with confirmed that they are encouraged and supported to undertake training one staff member said she “felt supported by management”. Staff also confirmed that they receive regular supervision, those who were asked confirmed it was a positive experience as it enable them to discuss issues such as training and personal development. Queens Lodge DS0000014675.V265063.R01.S.doc Version 5.0 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): 42 The health and safety of residents is generally promoted and protected. EVIDENCE: Risk assessments are carried out and training is provided for ensuring safe working practices such as manual handling, fire safety, first aid, food hygiene and infection control are in place and understood. However the home could not demonstrate that all staff have received fire safety instruction at the recommended intervals of 6 monthly for day staff and 3 monthly night staff. Maintenance records indicate appropriate health and safety checks identified in 42.3 of this standard are carried out. Queens Lodge DS0000014675.V265063.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score X X 3 3 X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 X X X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Queens Lodge Score X X 3 X Standard No 37 38 39 40 41 42 43 Score X X X X X 2 X DS0000014675.V265063.R01.S.doc Version 5.0 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 2 Standard YA6 YA42 Regulation 15 23 Requirement A written plan as to how residents individual needs will be met must be developed. The provider must ensure that all staff receive fire training at the recommended intervals of 6 monthly day staff and 3 monthly night staff. Timescale for action 27/01/06 27/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Queens Lodge DS0000014675.V265063.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Worthing LO 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex BN11 1RY 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 Queens Lodge DS0000014675.V265063.R01.S.doc Version 5.0 Page 21 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!