Inspection on 10/04/06 for Shenley Lodge

This inspection was carried out on 10th April 2006.

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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Shenley Lodge 07/08/07

Shenley Lodge 11/10/05

Shenley Lodge 17/05/05

Shenley Lodge 12/08/04

Shenley Lodge 27/04/04

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

CARE HOME ADULTS 18-65 Shenley Lodge 34 Abbey Road Enfield Middlesex EN1 2QN Lead Inspector Tom McKervey Key Unannounced Inspection 10th April 2006 10:00 Shenley Lodge DS0000010680.V287872.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 Shenley Lodge DS0000010680.V287872.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. Shenley Lodge DS0000010680.V287872.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Shenley Lodge Address 34 Abbey Road Enfield Middlesex EN1 2QN 020 8363 1173 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr V Kowlessur Mr Vijayekoomar Kowlessur Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Shenley Lodge DS0000010680.V287872.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Two specified service users who are over 65 years of age may remain accommodated in the home The home must advise the regulating authority at such times as either of the specified service users vacates the home. Date of last inspection 11th October 2005 Brief Description of the Service: Shenley Lodge is a private care home, which opened in 1993. The home is registered to provide care for seven adults with a learning disability. The provider, who also owns another home in the locality, is also the registered manager. The service is provided in a large detached house in a very pleasant residential area of Bush Hill Park, Enfield. The accommodation consists of five single bedrooms upstairs, one of which has en-suite facilities, and one double room on the ground floor, with en-suite shower and toilet. There is a lounge and separate dining room and kitchen on the ground floor. There is a small garden and driveway at the front of the premises, and a large pleasant garden at the rear, which is accessible by the residents. The home is close to shops and amenities and there are good public transport links. A minibus is available for taking residents to day centres and other activities in the community. The fees for the home range from £550 to £570 per week. Following “Inspecting for Better Lives”, the provider must make information available about the service, including inspection reports. Shenley Lodge DS0000010680.V287872.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection, which took place over a period of four hours, was carried out as part of the Commission’s inspection programme and to check compliance with the key standards. There were seven residents living in the home and there were no vacancies. The case files of two residents, one of whom had recently been admitted to the home, were “case tracked”. Both of these residents were spoken to and observed during the inspection. However, neither person had verbal skills. The manager and deputy were both present during the inspection, which consisted of a tour of the premises, examining residents’ and staffs’ records, and other documents relating to the running of the home. There were no visitors to the home during the inspection. What the service does well: What has improved since the last inspection? Shenley Lodge DS0000010680.V287872.R01.S.doc Version 5.1 Page 6 Significant improvements have been made to the environment by the installation of new double-glazing in many areas of the home, and the exterior of the building had been repainted. A bedroom has had a major upgrade, including the provision of en-suite facilities, and several internal areas have been redecorated. Other maintenance issues from the last inspection report have also been addressed. Service users’ contracts now include the service fees charged. 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. Shenley Lodge DS0000010680.V287872.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 Shenley Lodge DS0000010680.V287872.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, 2, 3, & 5 There is incomplete information in the Service User Guide and residents’ contracts about the full cost of the service, which includes residents’ holidays. New service users are able to visit the home prior to moving in. EVIDENCE: A new resident had recently been admitted to the home. This person was “case tracked”. Their file contained a comprehensive assessment from the referring local authority’s care manager, in addition to the home’s own assessment. The individual’s likes and dislikes and preferred method of approach were covered in the assessment. The resident’s progress was documented for the first four weeks of residency. This person was non-verbal, but through observation of their behaviour and reading their records, they appeared to be happy and well settled in the home. There was a record of the new resident’s contract, which included the terms and conditions of the service and the fees charged. However, the Service User Guide and contract made no reference to the cost of holidays, which is not covered in the fees, and a requirement is made for this to be stated in all residents’ contracts and the Service User Guide. Shenley Lodge DS0000010680.V287872.R01.S.doc Version 5.1 Page 9 Staff records show that they receive training appropriate to the needs of people with learning disabilities, and thorough observation of their interactions with the residents, the member of staff present, demonstrated their ability to communicate effectively with them. The manager stated that prior to moving in, the new resident, and their relatives had visited the home. Shenley Lodge DS0000010680.V287872.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, 7, 8 & 9 The residents are supported to exercise choices about how they spent their time. Risk assessments are documented to protect residents when participating in activities within and outside the home. EVIDENCE: Two care plans of residents who were case tracked were examined. They contained assessments of needs and goals were set appropriately. The care plans were reviewed monthly, which exceeds the standard of six-monthly reviews. Appropriate risk assessments were in place regarding residents’ activities within the home and out in the community. Following the last inspection, written authorisation had been obtained by a resident’s care manager for a move from a single to a double bedroom. This was in keeping with the resident’s wishes and they appeared to be happy with the move. The inspector saw in the records of two service users, who had limited verbal communication, that their preferences were noted about a range of options. The daily records reflected that these choices were respected. There was also Shenley Lodge DS0000010680.V287872.R01.S.doc Version 5.1 Page 11 evidence that residents chose what to eat, and this was recorded in a special book. Regular meetings are held between the staff and residents where residents are consulted about the day-to-day management of the home. These meetings are minuted. Shenley Lodge DS0000010680.V287872.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): 11, 12, 13, 15 & 17 The residents have a good quality of life in a homely atmosphere and are integrated in the community. Appropriate leisure and learning opportunities are provided to promote residents’ independence. Meals are varied and residents are able to choose what they want to eat. EVIDENCE: Six of the seven residents attend various day centres during the week. The visitor’s book recorded an advocate’s regular visits to one resident who is blind. There was evidence of residents going out for meals at pubs and restaurants, and attending church services. At the beginning of the inspection, a resident was out with a member of staff in the car, dropping off another resident at the day centre. Shenley Lodge DS0000010680.V287872.R01.S.doc Version 5.1 Page 13 The inspector saw evidence that a care review was to be held by a social worker within a few days, to discuss options for day care for the remaining resident who did not currently have a day centre. There were records of visitors by relatives and an advocate to service users and of visits home. An inspection of the kitchen showed that there was plenty of food available, including fresh fruit. The menus, which were varied and wholesome, were represented in pictures so that residents who are non-verbal can point to their choice. Food was safely stored and the temperatures of the fridge and freezer were monitored. Shenley Lodge DS0000010680.V287872.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): 18, 19 & 20 The healthcare needs of the majority of the residents are being met with the support of the G.P and community learning disability team. However, better monitoring of residents’ weights is needed where there is cause for concern. Steps need to be taken to protect the privacy of residents, and the safety of the administration of medicines needs to be improved. EVIDENCE: There are male and female staff available to provide personal support to residents of both gender. The inspector noted that there wasn’t a screen available in the double bedroom to protect the privacy of the two residents, and a requirement is made for this to be provided. An upstairs toilet could only be locked externally, which compromised residents’ privacy when using the toilet. A requirement is made for a two-way locking device to be fitted to the door. The new resident had been registered with the local G.P. An examination of the case files showed records of appointments with G.P’s, including general checkShenley Lodge DS0000010680.V287872.R01.S.doc Version 5.1 Page 15 ups. Residents also receive input from professionals in the Community Learning Disability team. The records of the administration of medicines were satisfactory. However, examples of staffs’ signatures were not in evidence and the times of administration were missing from the dosette boxes. This could lead to medication not being given at the correct times. A requirement is made to address these issues. A resident who was losing weight had been referred to a specialist and was waiting for an appointment. However, this person’s records showed that although he had lost 4Kgs in weight, they had not been weighed in the past two months. A requirement is made to more closely monitor residents’ weights. Shenley Lodge DS0000010680.V287872.R01.S.doc Version 5.1 Page 16 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 & 23 Residents are safeguarded procedures and staff training. EVIDENCE: The last recorded complaint was in 2001 and the manager stated that there were no outstanding issues at the time of the inspection. There were records of staff attendance at adult protection training. The member of staff on duty during the inspection was knowledgeable about the procedures regarding reporting concerns about abuse. The residents who were present during the inspection appeared happy and well cared for. from potential abuse through appropriate Shenley Lodge DS0000010680.V287872.R01.S.doc Version 5.1 Page 17 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, 26, 27 & 30 The residents live in a home where the overall standard of the environment is pleasing, homely and comfortable. Residents’ bedrooms reflect their independence through their personal possessions. The rubbish outside the home detracts from the appearance and cleanliness of the home. EVIDENCE: A tour of the interior and exterior of the premises was carried out. The standard of décor in the home was generally good, and there was a homely atmosphere. The furniture and fittings were domestic in style and were in a good state of repair. Several windows had been replaced with double-glazing and a bedroom had been substantially refurbished to provide en-suite facilities. Following the last inspection, the toilet roll holders were replaced in all the toilets, and the floor covering in the laundry been sealed. All the bedrooms were visited. They were spacious and appropriately furnished, with evidence of personal possessions. Shenley Lodge DS0000010680.V287872.R01.S.doc Version 5.1 Page 18 The home was generally clean and tidy. A new cleaner had been employed since the last inspection. However, there was rubbish lying around outside the building, which had been spilled from refuse bags. A requirement is made for rubbish to be properly disposed of. Shenley Lodge DS0000010680.V287872.R01.S.doc Version 5.1 Page 19 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 & 36 Staff receive training appropriate to the needs of the residents and are regularly support through formal supervision. There are poor staff recruitment practices, which could potentially put residents at risk. The staff rota does not accurately reflect the number of care staff available to meet the residents’ needs. EVIDENCE: The stated staffing levels are two staff in the morning, three in the evening, and one person sleeping at night. However, at the time of inspection, the rota indicated that only one care staff was on duty that morning. The manager, who came to the home during the inspection, stated that he was the second person on duty, but his duties were not recorded on the staff rota. A requirement is made to ensure that this is corrected. One new person had started working at the home. Their records and two other staffs’ were examined. Shenley Lodge DS0000010680.V287872.R01.S.doc Version 5.1 Page 20 Current Criminal Records Bureau, (CRB) clearances, and two written references had not been obtained for these staff, and a written induction had been undertaken. An immediate requirement was made for Protection of Vulnerable Adults, (POVA) 1st checks and references from the last employer to be obtained for these staff and to be made available for inspection. (Since this inspection, the manager has complied with this requirement, by supplying these documents.) There were records of regular supervision of staff, and three staff had attained National Vocational Qualification, (NVQ) level 3, and the deputy manager was currently undergoing NVQ 4. Shenley Lodge DS0000010680.V287872.R01.S.doc Version 5.1 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40 & 42 Appropriately trained and experienced persons manage the home, and there are policies and procedures in place to guide staff in caring for the residents. Residents are consulted about the running of the home and their safety and welfare are safeguarded by good health and safety practices. EVIDENCE: The manager, who is also the proprietor, has managed the home since 1993, and has attained NVQ Level 4 in management studies. He is supported by a deputy who has worked at the home for a substantial period of time. He is currently undergoing NVQ Level 4. The deputy, who was present during the inspection, said that he was well supported by the manager in his duties. There are appropriate policies and procedures in place to support the efficient running of the home. Shenley Lodge DS0000010680.V287872.R01.S.doc Version 5.1 Page 22 Meetings between the residents and staff are held, when issues to do with the running of the home and general activities are discussed. These meetings provide opportunities for the residents to put forward their views and express any concerns. A new central heating boiler was installed in September 05. Fire equipment was up to date and fire alarms were tested and drills carried out at appropriate intervals. Staff had been trained in fire prevention. There was a current employer’s certificate of liability on display. Shenley Lodge DS0000010680.V287872.R01.S.doc Version 5.1 Page 23 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 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 3 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 2 34 1 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 X 3 X 3 3 X 3 X Shenley Lodge DS0000010680.V287872.R01.S.doc Version 5.1 Page 24 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 & YA5 YA18 Regulation 5(1)(c) Requirement Timescale for action 31/05/06 2 12(4)(a) 3 YA18 12(4)(a) 4 YA19 12(1)(a) The registered person must ensure that the Service User Guide and residents’ contracts include information about payment for holidays. The registered person must 31/05/06 ensure that the privacy of two specific residents is protected by the provision of screens in their bedroom. The registered person must fit a 31/05/06 two-way lock to the upstairs toilet to safeguard the privacy of the residents. The registered person must 31/05/06 ensure that there is accurate and regular recording of residents’ weights and action is taken if a resident’s weight is giving concern. This requirement is restated from the last inspection. The previous timescale was 30/11/06 The registered person must ensure that the time of administration of medicines is clearly identified and examples of staffs’ signatures are provided. DS0000010680.V287872.R01.S.doc 5 YA2020 13(2) 31/05/06 Shenley Lodge Version 5.1 Page 25 6 YA3030 23(2)(d) 7 YA3333 17(2) Sch 4 7, 9, 19 8 YA3434 The registered person must 31/05/06 ensure that there is proper disposal of rubbish from the home. The registered person must 31/05/06 ensure that his duties in the home are clearly recorded on the staff rota. The registered person must 14/04/06 obtain POVA 1st checks and two written references for all staff who work in the home. This is an immediate requirement. 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 Shenley Lodge DS0000010680.V287872.R01.S.doc Version 5.1 Page 26 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. Extracts may not be used or reproduced without the express permission of CSCI Shenley Lodge DS0000010680.V287872.R01.S.doc Version 5.1 Page 27 - 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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