Inspection on 27/02/06 for Queens Lodge

This inspection was carried out on 27th 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 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 14 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 13/09/05

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 Inspection 27th February 2006 12:45 Queens Lodge DS0000017914.V282736.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 Queens Lodge DS0000017914.V282736.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. Queens Lodge DS0000017914.V282736.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Queens Lodge Address 3b Queens Road Colchester Essex C03 3NP 01206 575410 01206 575410 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) www.mencap.org.uk Royal Mencap Society Manager post vacant Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (6) of places Queens Lodge DS0000017914.V282736.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Persons of either sex, aged 65 years and over, who require care by reason of a learning disability (not to exceed 6 persons) Persons of either sex, aged 45 years and over, who require care by reason of a learning disability (not to exceed 6 persons) The total number of service users accommodated in the home must not exceed 6 persons 13th September 2005 Date of last inspection 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 DS0000017914.V282736.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 27th February 2006 over 4 hours. The manager was not on duty on the day of the inspection, the level of assistance and co-operation the inspector received from the deputy manager, support staff and service users was appreciated. 20 of the 43 National Minimum Standards relating to this care service were assessed with 11 being met. Overall the standard of care at Queens Lodge was good. What the service does well: What has improved since the last inspection? What they could do better: Prospective service users would benefit from the Statement of Purpose and the Service User Guide being further developed to reflect the accurate position and qualifications for the support staff and management team. The manager could further protect the health, safety and welfare of new service users by ensuring Queens Lodge had appropriate management strategies in place to meet the individual and complex needs of service users before they are admitted into the care home. Queens Lodge DS0000017914.V282736.R01.S.doc Version 5.1 Page 6 The previous inspection highlighted that the service users at Queens Lodge would benefit from redecoration and refurbishment of communal areas. This is still outstanding at this inspection visit however the deputy manager was able to report that quotes had obtained for the work to be undertaken and that the service users were to be involved in selecting paint colours within days of this visit. The staff training and development plan and supervision system had broken down during the period without a permanent manager in post. It was reported that these matters were being addressed and with support from the Mencap organisation would be effective by the next inspection visit. Staff records should continue to be developed to include all information required by NMS 34. 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 DS0000017914.V282736.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 Queens Lodge DS0000017914.V282736.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 and 2 • • Prospective service users did not have all the information they needed to make an informed choice about where to live. Prospective service users individual aspirations and needs were assessed before entering the home. EVIDENCE: The manager and deputy had progressed and developed the home’s Service User Guide and Statement of Purpose since the previous inspection visit. The support staff team were more accurately reflected within these documents however the manager’s details had not been completed. This standard was considered partially met. A new service user had been admitted on the day of the inspection from hospital. The individual’s healthcare needs on discharge from hospital meant that the previous service, a supported living unit, were temporarily unable to meet their healthcare needs. It was evident through observation and discussion that the staff team at Queens Lodge were not able to communicate with this service user with complex needs. It was reported that Mencap were to arrange staffing to meet this individual’s needs however this had not been actioned at the time of this inspection. Subsequent telephone conversation with the manager of Queens Lodge on 10th March 2006 confirmed that a member of staff from the supported living service had been seconded to work at Queens Lodge to work with this service user and to train the staff in the individual’s preferred form of communication. Queens Lodge DS0000017914.V282736.R01.S.doc Version 5.1 Page 9 Evidence was available to demonstrate that a pre admission assessment of the service user’s individual needs had been made prior to admission. Multi disciplinary teams had met twice before admission of this service user into Queens Lodge. Queens Lodge DS0000017914.V282736.R01.S.doc Version 5.1 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 and 9 • Service users could be confident their assessed and changing needs and personal goals were reflected in their individual plans of care. • Service users were supported to take risks as part of an independent lifestyle. EVIDENCE: The service users’ care plans sampled at this inspection contained confirmation that reviews had taken place of individuals’ care needs, covering mental health needs and physical and emotional care needs. The care plans demonstrated how current specialist requirements were met and what actions were required on the part of the service user and the support workers to achieve set goals. The files contained evidence of some service user involvement in the formulation of their own plans of care. Care plan reviews were reported to take place regularly, care plans contained evidence to confirm this. Staff supported service users in taking responsible risks. Risk assessments were contained within service users’ files. When a hazard or risk to service users’ health, safety or well being was identified, this was documented together with the actions to be taken by support staff and the service users to minimise or reduce the risk. Regular Queens Lodge DS0000017914.V282736.R01.S.doc Version 5.1 Page 11 reviews were undertaken to re-assess the level of risk and to evaluate the effectiveness of the strategy in place to reduce the identified risk. Where a risk assessment resulted in an infringement of individual’s rights the deputy manager was able to demonstrate that this had been recorded appropriately. Queens Lodge DS0000017914.V282736.R01.S.doc Version 5.1 Page 12 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): 12,13,15 and 17 • Where possible service users were supported to take part in age and peer appropriate activities. • Service users were part of the community. • Service users benefited from being supported to maintain personal and family relationships. • Service users were offered a healthy diet and enjoyed their meals and mealtimes. EVIDENCE: All the service users living at Queens Lodge were over the age of retirement and chose not to engage in work within the community. One service user attended cookery classes once per week and two attended college one day per week. There was no provision within the home’s budget to allow for a vehicle to assist the service users in accessing the community. Service users accessed the local community through leisure activities such as visiting the cinema, bowling, visiting pubs for social drinks and meals. Queens Lodge DS0000017914.V282736.R01.S.doc Version 5.1 Page 13 The deputy manager reported that service users’ families were invited to birthday and Christmas parties. 3 of the service users had independent advocates to act on their behalf. When any service user at the home developed medical problems the next of kin were contacted as a matter of course. The home operated a four weekly menu that was selected by the service users. A scrapbook was in the process of being developed to make it simpler for service users to demonstrate their choices to the support staff. Food hygiene refresher courses had not been provided for the staff team and the staff member cooking the service users’ meal on the day of the inspection did not have current basic food hygiene training. The food hygiene training provided by Mencap was delivered via distance learning. Staff reported that most of the service users living at Queens Lodge needed their food liquidising, chopping or mashing to allow them to eat it comfortably. It was reported that the food was presented as ‘visually pleasing’ as possible despite the mashing processes. Service users were not physically able to actively participate in the preparation of meals however some were able to confirm their input into the decision making processes. One staff member reported that if a service user ‘changed’ their mind and did not fancy the meal that had been selected and was being prepared for them an alternative would be found. The kitchen area was in need of refurbishment. Some cupboard doors did not close properly and most were scratched and marked. The deputy manager was able to confirm the kitchen was one of the areas quoted for redecoration. Scrutiny of cupboards and fridges confirmed that adequate food stocks of an acceptable quality were maintained for the service users. Queens Lodge DS0000017914.V282736.R01.S.doc Version 5.1 Page 14 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): EVIDENCE: These standards were not assessed at this visit. Queens Lodge DS0000017914.V282736.R01.S.doc Version 5.1 Page 15 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 and 23 • • Service users could be confident their views were listened to and acted upon. Service users were not adequately protected from abuse, neglect and self harm. EVIDENCE: The home had received one complaint since the previous inspection visit. This had been recorded appropriately and actioned within the 28 day timescale. An index system had been put into place to identify ‘at a glance’ if patterns or trends should emerge either in the nature of complaints or the subject of complaints. The home’s complaints policy and procedures were included within the Statement of Purpose and Service User Guide and contained contact details of the Commission for Social Care Inspection. Just 4 of the 11 staff working at Queens Lodge had received up to date training in the Protection of Vulnerable Adults from abuse. Two staff files were sampled at this inspection and one did not contain evidence that a Criminal record Bureau disclosure had been obtained. Queens Lodge DS0000017914.V282736.R01.S.doc Version 5.1 Page 16 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 and 30 • Service users lived in an environment that required some refurbishment. • The home appeared to be clean and hygienic on the day of this inspection. EVIDENCE: The home was accessible to service users in wheelchairs but doorways were too narrow to allow the chairs to pass through easily and safely. 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 damaged paintwork. The décor throughout the communal areas of the home, including the kitchen, was tired and in need of attention. The deputy manager provided quotes obtained from builders/decorators to undertake this work. It was reported that a quote had been accepted and that colour charts were to be delivered for the service users to exercise their choices in respect of their communal living areas. Queens Lodge did not benefit from dedicated domestic staff. Cleaning was undertaken by support staff members daily. On the day of the inspection the home appeared adequately clean and free from offensive odours. Policies and procedures regarding the control of infection were in place however support staff had not received training in this area. Queens Lodge DS0000017914.V282736.R01.S.doc Version 5.1 Page 17 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 and 36 • • • Service users health, safety and well being would benefit from the staff team receiving appropriate training and refresher courses that are scheduled, planned and budgeted for. The home’s recruitment practices supported and protected the service users. Service users did not benefit from a well supported and supervised staff and management team. EVIDENCE: Staff members were observed to provide professional and competent care to the service users at Queens Lodge. All the service users spoken with during this inspection process praised the commitment and dedication of the staff team however support staff had not been provided with the mandatory training and refresher training required to update their skills and continue to protect the health, safety and welfare of the service users. The home had a staff development and training plan that identified which staff members were required to attend particular courses. Evidence was available and discussion with staff confirmed that not all staff had moving and handling, basic food hygiene or Protection of Vulnerable Adults from abuse training. The organisation did not provide training in the control of infection. It was reported that Mencap had chosen to secure a new training provider for the NVQ training, as they had not received consistency from their previous Queens Lodge DS0000017914.V282736.R01.S.doc Version 5.1 Page 18 providers. One staff member reported having 5 different assessors whilst undertaking their NVQ level 2 qualification. Just two members of staff had completed NVQ level 2. This did not meet the required ratio of 50 of staff to have achieved this by Dec 2005. Deputy manager was planning to undertake NVQ level 4 in care. Two staff files were sampled at this inspection visit. One contained all items required by this standard however one file did not include a photograph of the staff member. This service had experienced some staffing and recruitment difficulties during the year prior to this inspection. The organisation had recruited a permanent manager who, it was reported, will apply to be registered with the Commission for Social Care Inspection. Staff supervision sessions had not taken place during this period of instability in the staffing structure. The deputy manager was able to demonstrate that formal supervisions were now scheduled and planned for. It was reported that annual appraisals did not take place routinely within the organisation. Queens Lodge DS0000017914.V282736.R01.S.doc Version 5.1 Page 19 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): 38,39 and 42 • • • Service users benefited from the ethos, leadership and management approach of the home. Service users and their families/representatives could be confident that their views underpinned all self monitoring, review and development of the home. The health and safety of service users was not always promoted and protected. EVIDENCE: The staff reported that the manager’s approach was open, inclusive and supportive. The deputy manager was able to demonstrate area where improvements had been made in the months the manager had been in post. The home had undertaken a service user survey in September 2005. The inspector was provided with a summary of the responses and an improvement plan addressing service shortfalls. Queens Lodge DS0000017914.V282736.R01.S.doc Version 5.1 Page 20 Evidence was present to confirm that electrical system/fire alarm/water temperature/portable electrical appliance/hoist/gas/wheelchair testing had taken place. COSHH records were well maintained with relevant risk assessments and validations in place. The COSHH cupboard was not locked during this visit.. Mandatory training in areas of health and safety including moving and handling, infection control and food hygiene had not been provided/updated. All accidents, injuries, incidents of illness or communicable disease, or death of a service user were recorded and reported appropriately. Queens Lodge DS0000017914.V282736.R01.S.doc Version 5.1 Page 21 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 2 2 2 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 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 1 33 1 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 X 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X X 3 3 X X 2 X Queens Lodge DS0000017914.V282736.R01.S.doc Version 5.1 Page 22 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 4(1) Requirement Timescale for action 30/06/06 2 YA2 14(1)(a) 14 (1)(d) 3 YA17 16(2)(j) 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 24/02/06 not provide accommodation to a service user at the care home unless, so far as it is practicable to do so, his/her needs have been assessed by a suitably qualified or trained person. The registered person shall ensure that, with having regard to the assessment the care home is suitable for the purpose of meeting the service user’s needs in respect of his/her health and welfare. The registered person shall, 30/06/06 having regard to the number and needs of service users, DS0000017914.V282736.R01.S.doc Version 5.1 Page 23 Queens Lodge 4 YA42 YA23 5 YA24 6 YA24 7 YA42 YA30 8 YA35 YA33 YA32 after consultation with the environmental health authority, make suitable arrangements for maintaining satisfactory standards of food hygiene within the home. This specifically relates to training staff in Basic food hygiene. 13(6) The registered person shall make arrangements by training staff or by other measures to prevent service users being harmed or suffering abuse or being placed at risk or harm from abuse This specifically relates to staff training in PoVA 23(2)(a) 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. 23(2)(d) 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. 13(3) 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. 18(1)(a)(c) The registered person shall having regard to the size of the care home, the Statement of Purpose and the number and needs of the service users (a) ensure that at all times suitably qualified competent and experienced DS0000017914.V282736.R01.S.doc 30/06/06 30/06/06 30/06/06 30/06/06 30/06/06 Queens Lodge Version 5.1 Page 24 9. YA36 18(2) 10. YA42 13(5) persons are working at the care home in such numbers as are appropriate for the health and welfare of service users. (c) Ensure that persons working at the care home receive training appropriate to the work they are to perform. The registered person shall ensure that persons working at the care home are appropriately supervised. This is a repeat requirement with an original agreed date for completion of 31st October 2005. The registered person shall make suitable arrangements to provide a safe system for moving and handling service users. 30/06/06 30/06/06 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 DS0000017914.V282736.R01.S.doc Version 5.1 Page 25 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. Extracts may not be used or reproduced without the express permission of CSCI Queens Lodge DS0000017914.V282736.R01.S.doc Version 5.1 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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