Inspection on 13/09/05 for Queens Lodge

This inspection was carried out on 13th September 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Queens Lodge 25/06/07

Queens Lodge 28/06/06

Queens Lodge 27/02/06

Queens Lodge 20/12/04

Queens Lodge 15/07/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Queens Lodge 3b Queens Road Colchester Essex C03 3NP Lead Inspector Jane Greaves Unannounced 13 September 2005 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 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 Stationary 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 I56-I05 S17914 Queens Lodge V248699 130905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Queens Lodge Address 3b Queens Road Colchester Essex CO3 3NP. 01206 575410 01206 575410 h3041@mencap.org.uk Royal Mencap Society Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Care Home (CRH) 6 Category(ies) of Learning disability over 65 years of age (LD(E)) registration, with number - 6 (both sexes) of places Learning disability (LD) - 6 (both sexes) Queens Lodge I56-I05 S17914 Queens Lodge V248699 130905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, aged 65 years and over, who require care by reason of a learning disability (not to exceed 6 persons). 2. Persons of either sex, aged 45 years and over, who require care by reason of a learning disability (not to exceed 6 persons). Date of last inspection 20 December 2004 Brief Description of the Service: Queens Lodge is owned by the Royal MENCAP Society. The home provides residential care for 6 individuals with learning disabilities, some of whom may be over 65. Accommodation is offered in a bungalow situated in a residential area on the outskirts of Colchester whereby service users can access local facilities. The premises have been extended to provide extra communal space. All rooms are single occupation. There is parking to the side of the property and a pleasant garden to the rear. Queens Lodge I56-I05 S17914 Queens Lodge V248699 130905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This routine unannounced inspection took place on 13th September 2005 over 4 1/2 hours. 18 of the National Minimum Standards were assessed and 8 were met. During the inspection process the inspector gathered views from the 4 people living at Queens Lodge, the deputy acting manager, a shift leader and 5 support staff. Overall the standard of care at Queens Lodge was observed to be good. What the service does well: What has improved since the last inspection? What they could do better: The service users living at Queens Lodge would benefit from the appointment of a permanent manager for the service. The home had experienced difficulty over the past year with recruiting a manager. The service users would benefit from the home being refurbished and redecorated. Where doorways were not adequate for easy wheelchair access there was damage to the doorframes and the décor was tired. Service users would benefit from more regular reviews of their plans of care in order to be assured that their needs were met. At this inspection the acting deputy manager was not able to demonstrate the recruitment practices, supervision processes or accessibility of the home’s policies and procedures. Queens Lodge I56-I05 S17914 Queens Lodge V248699 130905 Stage 4.doc Version 1.40 Page 6 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 I56-I05 S17914 Queens Lodge V248699 130905 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Queens Lodge I56-I05 S17914 Queens Lodge V248699 130905 Stage 4.doc Version 1.40 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 standard(s) 1, 4 and 5 Prospective service users did not have all the information they needed to make an informed decision about where to live. Prospective service users had the opportunity to visit and to ‘test drive’ the home. Each service user had an individual statement of terms and conditions within the home. EVIDENCE: The home’s Service User Guide and Statement of Purpose did not accurately reflect the current staffing team or the qualifications held. Details of previous staff members were included while current staff were not represented. A prospective service user had recently visited the home on a few occasions to meet the staff team, the service users and to experience the house routines before making the choice to move in permanently. The home offered prospective service users a 12 week trial period to settle in. Service users’ personal files contained a statement of terms and conditions, including details of the personal support and facilities provided, arrangements for reviewing needs and progress and the rights and responsibilities of both parties. Queens Lodge I56-I05 S17914 Queens Lodge V248699 130905 Stage 4.doc Version 1.40 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 standard(s) 6, 7 and 9 Service users could not be confident their changing needs were reflected in their individual plan of care. Service users were supported to make decisions about their lives. Service users were not adequately supported to take risks as part of an independent lifestyle. EVIDENCE: Each service user living at Queens Lodge had an individual plan of care identifying needs and detailing support required. The acting deputy manager was not able to demonstrate that the care plans had been regularly reviewed or that the service users’ changing needs had been documented. The care plans contained a great deal of information but required updating to reflect the changes in the service users’ needs and requirements. The people living at Queens Lodge were supported by the staff team to vote and to make decisions affecting their lives. Advocacy services had been secured for two service users. Queens Lodge I56-I05 S17914 Queens Lodge V248699 130905 Stage 4.doc Version 1.40 Page 10 Risk assessments were present on each service user’s care plan for activities such as smoking, slips, and falls and wheelchair usage. One disabled service user chose to make cups of coffee; there was no assessment of risk on file for this activity. There was no evidence of regular reviews of the risk assessments to take into account the changing needs and abilities of the service users. Queens Lodge I56-I05 S17914 Queens Lodge V248699 130905 Stage 4.doc Version 1.40 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 standard(s) 11, 12, 14 and 16 Service users had opportunities for personal development. Service users were able to take part in limited age and peer appropriate activities. Service users engaged in leisure activities. Service users’ rights were respected and responsibilities recognised in their daily lives. EVIDENCE: Two service users chose to attend college one day per week. On the day of the inspection one service user attended a music awareness class. One service user had expressed an interest in finding some employment and had been supported to access the job centre. Queens Lodge I56-I05 S17914 Queens Lodge V248699 130905 Stage 4.doc Version 1.40 Page 12 At the time of the previous inspection two service users had been in receipt of one to one care provision from social services. These hours amounted to 5 hours daily and 20 hours per week respectively. This support had been withdrawn leaving the two service users frequently bored and frustrated. The staff team had secured advocacy services to support the service users in communicating their needs to social services. The staff ensured that the service users went for an outing at least once daily and supported them to attend football matches, go to the cinema, shop, bake and visit the local Pub. Staff members reported that often they undertook these activities with the service users in their off duty time because there were not sufficient care hours available since the social services provision had been cut. Service users spoke of enjoying social time with the staff members and a pleasant friendly atmosphere was present in the home. Service users were seen to be treated with respect and dignity on the day of the inspection. Locks were fitted to bedroom doors and keys were available to service users if they chose to lock their rooms. Service users reported that if they wished to go and spend quiet time alone this was respected and that their own rooms were kept private to them. One bedroom was in the process of being decorated in a vibrant colour chosen by the service user and a collection of matching colourful accessories had been selected to complete the effect. The service users received regular visits from a neighbouring cat; this had prompted discussions about obtaining a house pet. The acting deputy manager reported that the service users were trying to decide between a rabbit and a cat. Queens Lodge I56-I05 S17914 Queens Lodge V248699 130905 Stage 4.doc Version 1.40 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 standard(s) 18 and 21 Service users received personal support in the way they preferred and required. The ageing, illness and death of a service user was handled with respect and as the individual would wish. EVIDENCE: The staff team at Queens Lodge provided sensitive and flexible personal support and care to maximise service users’ privacy and dignity. Induction training for all new staff included protecting service users’ dignity. Personal support and care were reported to be delivered in private. Service users confirmed they went to bed when they wished and rose when they wished, mealtimes were set but flexible around service users’ activities. The acting deputy manager was able to demonstrate that the service users’ wishes concerning terminal care were discussed and were carried out. Palliative care support and advice had been sought by the home when needed. Queens Lodge I56-I05 S17914 Queens Lodge V248699 130905 Stage 4.doc Version 1.40 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 standard(s) 22 Service users were confident their views were listened to and acted upon. EVIDENCE: Queens Lodge had a clear and effective complaints procedure that included the stages and timescales for the process. This document required amending to include the correct contact details for the Commission for Social Care Inspection. The home had not received any complaints since the previous inspection. The previous inspection report included a recommendation of good practice for an index page at the front of the complaints folder where patterns or trends emerging would be easily identified; this had not been actioned. Service users confirmed that they were aware of how to make a complaint one to one with staff members. Queens Lodge I56-I05 S17914 Queens Lodge V248699 130905 Stage 4.doc Version 1.40 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 standard(s) 24 and 30 Service users lived in an environment that required some refurbishment. The home appeared clean and hygienic on the day of the inspection. EVIDENCE: The home was accessible to service users in wheelchairs but doorways were only just wide enough to allow the chairs to pass through. Service users reported they had damaged their knuckles many times whilst negotiating doorways in the building. Each doorframe was considerably damaged with roughened wood and badly damaged paintwork. The décor throughout the home was tired and needed attention; bathroom windows had catches missing. Queens Lodge did not benefit from dedicated domestic staff. Cleaning was undertaken by support staff on a daily basis. On the day of the inspection the home appeared adequately clean and free from offensive odours. Queens Lodge I56-I05 S17914 Queens Lodge V248699 130905 Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 36 Service users did not benefit from a formally supervised staff team. EVIDENCE: The acting deputy manager was not able to demonstrate that the staff team at Queens Lodge received a minimum of 6 formal 1:1 supervision sessions during the course of a year. Historically there had been a system of formal supervision within the home and the acting deputy manager assured the inspector that once the permanent manager had been appointed this system would be reinstated. Queens Lodge I56-I05 S17914 Queens Lodge V248699 130905 Stage 4.doc Version 1.40 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 and 39 Service users would further benefit from a permanent manager being appointed for the home. Service users could not be confident their views underpinned all selfmonitoring, review and development of the home. EVIDENCE: There had not been any stability within the management of the home for the past year. The organisation had experienced difficulty in recruiting a permanent manager to this post. Adverts had been placed in the press immediately prior to this inspection. The established support staff team provided service users with the stability they required and maintained their lifestyles within the home. The registered person had recently undertaken a review of service users’ feelings and opinions regarding the care and facilities offered at Queens Lodge. The reviews were completed by three of the four people living at the home; Queens Lodge I56-I05 S17914 Queens Lodge V248699 130905 Stage 4.doc Version 1.40 Page 18 the fourth person did not wish to complete a review form. The shift leader and acting deputy manager were not aware if these reviews were summarised and used to ‘drive’ the improvement and development plan for the home. A copy of the summary of the reviews and the resulting plan of action should be forwarded to the Commission for Social Care Inspection. Queens Lodge I56-I05 S17914 Queens Lodge V248699 130905 Stage 4.doc Version 1.40 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 x x 3 3 Standard No 22 23 ENVIRONMENT Score 2 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x 2 Standard No 11 12 13 14 15 16 17 3 2 x 3 x 3 x Standard No 31 32 33 34 35 36 Score x x x x x 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Queens Lodge Score 3 x x 3 Standard No 37 38 39 40 41 42 43 Score x 2 2 x x x x I56-I05 S17914 Queens Lodge V248699 130905 Stage 4.doc Version 1.40 Page 20 Are there any outstanding requirements from the last inspection? Yes 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 YA1 Regulation 4(1) Requirement The registered person must compile in relation to the care home a Statement of Purpose and Service User Guide which shall consist of a statement as to the matters listed in Schedule 1. THIS IS A REPEAT REQUIREMENT WITH AN ORIGINAL AGREED TIMESCALE OF 1st March 2005. The registered person shall keep the service users care plans under regular review. The registered person shall ensure any activities in which service users participate are so far as reasonably practicable free from avoidable risks. The registered person shall ensure that unnecessary risks to the health or safety of service users are identified and as far as possible eliminated. The registered person shall, having regard to the size of the care home and the number and needs of service users, consult service users about their social interests, and make arrangements to enable them to engage in local, social and Timescale for action 31st October 2005 2. 3. YA6 YA9 15(2) 13(4)(b) 31st October 2005 31st October 2005 31st October 2005 31st October 2005 4. YA9 13(4)(c) 5. YA12 16(m) Queens Lodge I56-I05 S17914 Queens Lodge V248699 130905 Stage 4.doc Version 1.40 Page 21 community activities. 6. YA12 16(n) The registered person shall, having regard to the size of the care home and the number and needs of service users, consult service users about the programme of activities arranged by or on behalf of the care home, and provide facilities for recreation including, having regard to the needs of service users, activities in relation to recreation, fitness and training. The registered person shall, having regard to the number and needs of service users, ensure the physical design and layout of the premises to be used as the care home meet the needs of the service users. The registered person shall, having regard to the number and needs of the service users ensure that all parts of the care home are kept clean and reasonably decorated. The registered person shall make suitable arrangements by training staff or other measures to prevent infection, toxic conditions and the spread of infection at the care home. The registered person shall ensure that persons working at the care home are appropriately supervised. The registered person shall maintain in the care home the records specified in Schedule 4. (This specifically relates to staff records). The registered person shall establish and maintain a system for reviewing at appropriate intervals and improving the quality of care provided at the care home. The registered person shall supply to the 31st October 2005 7. YA24 23(2)(a) 31st December 2005 8. YA24 23(2)(d) 31st December 2005 9. YA30 13(3) 31st October 2005 10. YA36 18(2) 31st October 2005 31st october 2005 31st October 2005 11. YA36 17 12. YA39 24 Queens Lodge I56-I05 S17914 Queens Lodge V248699 130905 Stage 4.doc Version 1.40 Page 22 Commission a report in respect of any review conducted and make a copy of the report available to service users. THIS IS A REPEAT REQUIREMENT FOR THE SECOND TIME WITH AN ORIGINAL AGREED TIMESCALE OF 31st DECEMBER 2004. 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 YA22 Good Practice Recommendations It is a recommendation of good practice for the registered person to develop a complaints log to be maintained within the home in order to identify patterns or trends emerging. THIS IS A REPEAT RECOMMENDATION OF GOOD PRACTICE ORIGINALLY MADE IN DECEMBER 2004 It is recommended that the Organisation continues efforts to secure a permanent manager in post to promote stability within the unit. 2. YA38 Queens Lodge I56-I05 S17914 Queens Lodge V248699 130905 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection 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. Extracts may not be used or reproduced without the express permission of CSCI Queens Lodge I56-I05 S17914 Queens Lodge V248699 130905 Stage 4.doc Version 1.40 Page 24 - 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. 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