Inspection on 11/10/05 for Shenley Lodge

This inspection was carried out on 11th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 5 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 10/04/06

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 Unannounced Inspection 11th October 2005 10:00 Shenley Lodge DS0000010680.V251150.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 Shenley Lodge DS0000010680.V251150.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. Shenley Lodge DS0000010680.V251150.R01.S.doc Version 5.0 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.V251150.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 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. Mr Vijayekoomar Kowlessur`s registration as the manager of Shenley Lodge is subject to his continued compliance with the requirements of the Care Home Regulations 2001 and the National Minimum Standards for Care Homes for Adults Standards (18-65). This compliance will be assessed through routine unannounced inspections by the Commission for Social Care Inspection. 17th May 2005 Date of last inspection Brief Description of the Service: Shenley Lodge is a private care home, 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 accomodation consists of five single bedrooms upstairs, and one double room which is situated on the ground floor. There is an adapted en-suite shower in the double bedroom for a wheelchair user. 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 amenites and there are good public transport links. A minibus is available for taking residents to day centres and other activities in the community. Shenley Lodge DS0000010680.V251150.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 a period of two-and-a-half hours. The purpose of the inspection was to monitor the quality of the service, and particularly, progress made since the last inspection. At the time of this inspection, there were six residents living in the home, three of whom were spoken to. There was one vacancy, and work was in progress to provide en-suite facilities in the vacant room. The manager and deputy were both present during the inspection, which consisted of a tour of the premises, residents’ records, and documents relating to the running of the home. In addition to the manager and deputy, one other member of staff was spoken to independently. What the service does well: What has improved since the last inspection? A care plan is now available for all the residents. The fire extinguishers have been tested within the last year and an application for a member of staff has been sent to the Criminal Records Bureau. Shenley Lodge DS0000010680.V251150.R01.S.doc Version 5.0 Page 6 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.V251150.R01.S.doc Version 5.0 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.V251150.R01.S.doc Version 5.0 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): 5 A resident’s change of bedroom has not been recorded in their contract of terms and conditions. This could result in the resident being incorrectly charged for the service. EVIDENCE: No new service users have been admitted to the home since the last inspection. Since the last inspection, a resident had moved from a single room to a double room, which the manager stated would affect the fees charged. This move was not recorded in the person’s contract. A requirement is made that any approved change of room for any resident is reflected in the person’s contract, together with any alteration in the fees charged. Shenley Lodge DS0000010680.V251150.R01.S.doc Version 5.0 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 the following standard(s): 6, 7 & 9 Appropriate guidance for staff is provided in residents’ care plans, which are kept up to date. A resident’s or their representative’s consent to a change of room has not been recorded. This could result in an infringement of this resident’s rights and their ability to make choices. EVIDENCE: Two care plans 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. Annual care reviews by social workers were also documented. Appropriate risk assessments were in place regarding residents’ activities within the home and out in the community. As noted above under Standard 5, a resident had been moved from a single, in to a double room. There was no record of consent to this move by the resident, who has learning difficulties. The manager stated that the resident had demonstrated a preference for a downstairs room, and the move was made after consultation with the resident’s social worker. However, there was no record of the social worker’s approval. A requirement is made to obtain written consent for this move from the person’s social worker. Shenley Lodge DS0000010680.V251150.R01.S.doc Version 5.0 Page 10 Shenley Lodge DS0000010680.V251150.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): 11, 14, 16 & 17 The residents have a good quality of life in a homely atmosphere and are integrated in the community. With the exception of one issue affecting a specific resident, the residents are able to exercise choice about their lives in the home. EVIDENCE: Five of the residents attend various day centres during the week. An advocate visits one resident who is blind, twice a week. There was evidence of residents going out for meals at pubs and restaurants, and attending church services. During the inspection, a resident was supported by a member of staff to go out for a walk. All the residents were supported on a weeklong holiday in October. In relation to Standard 16, there is a concern about a lack of evidence regarding a resident giving permission to move rooms, about which, a requirement is made. However, there was evidence that in other areas of residents’ lives, choices can be made. For instance, one resident during the inspection, was able to choose not to go to the day centre that day. There was also evidence that residents chose what to eat, and this was recorded in a special book. Shenley Lodge DS0000010680.V251150.R01.S.doc Version 5.0 Page 12 An inspection of the kitchen showed that there was plenty of food available, including fresh fruit. Menus are represented in pictures so that residents who are non-verbal can point to their choice. Shenley Lodge DS0000010680.V251150.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): 19 & 20 Medication is administered safely and a range of health professionals maintains residents’ health. Better monitoring and recording of residents’ weights is needed to ensure that their welfare is safeguarded. EVIDENCE: An examination of the case files showed records of appointments with G.P’s, including general check-ups. Residents also receive input from professionals in the Community Learning Disability team. There were records of service users’ weights being monitored regularly. However, it was noted that according to one resident’s record, they had lost considerable weight over a very short time. A discussion with the manager and deputy about this issue indicated that the scales were faulty or the weight was not being recorded accurately, as the resident did not appear to be ill. A requirement is made about this issue. The administration of medicines was found to be in order and PRN medication was appropriately recorded. Shenley Lodge DS0000010680.V251150.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 & 23 Residents are safeguarded from potential abuse through appropriate 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. Shenley Lodge DS0000010680.V251150.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): 24, 25 & 30 The overall standard of the environment is pleasing, homely and comfortable. However, a bathroom and a bedroom are in need of redecoration, and the poor finish to the laundry floor could present a health and safety hazard and damage to the floor. EVIDENCE: A tour 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. However, the upstairs bathroom needs redecoration, the floor needs resealing, and toilet roll holders need to be replaced in all the toilets. The floor covering in the laundry had been replaced but had not been sealed, which could result in the wooden floor being damaged by spillages. All the bedrooms were visited. They were spacious and appropriately furnished, with evidence of personal possessions. The ceiling in one bedroom was water stained and the room was in need of redecoration. Work was in progress to convert a vacant bedroom to provide en-suite facilities. Shenley Lodge DS0000010680.V251150.R01.S.doc Version 5.0 Page 16 At the time of the inspection, the home was clean and tidy and there were no offensive odours. Shenley Lodge DS0000010680.V251150.R01.S.doc Version 5.0 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): EVIDENCE: No new staff have been employed at the home since the last inspection, and these Standards have not been inspected. Shenley Lodge DS0000010680.V251150.R01.S.doc Version 5.0 Page 18 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): 39 & 42 There are systems in place to ascertain the views of residents about the running of the home, and there is appropriate monitoring undertaken to safeguard the health and safety of the residents. EVIDENCE: Two meetings with the residents were held in January and September when issues to do with the running of the home and general activities were discussed. These meetings provide opportunities for the residents to put forward their views and express any concerns. The fire log showed that the fire alarms were tested weekly and fire drills were carried out. The fire extinguishers had been recently tested. The temperatures of the fridge and freezer were monitored and food was stored safely. COSHH materials were safely stored. There was a valid insurance certificate on display. Shenley Lodge DS0000010680.V251150.R01.S.doc Version 5.0 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 X X X X 2 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 2 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 X X X X 3 LIFESTYLES Standard No Score 11 3 12 X 13 X 14 3 15 X 16 2 17 Standard No 31 32 33 34 35 36 Score X X X X X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Shenley Lodge Score X 2 3 X Standard No 37 38 39 40 41 42 43 Score X X 3 X X 3 X DS0000010680.V251150.R01.S.doc Version 5.0 Page 20 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 YA5 Regulation 5(1)(c) Requirement The registered person must ensure that a resident’s contract is updated to include changes to the accommodation and fees. The registered person must ensure that evidence is provided that a specific resident or their representative has agreed to moving to another bedroom. The registered person must ensure that there is accurate recording of residents’ weights and action is taken if a resident’s weight is giving concern. The registered person must ensure that the covering on the laundry floor is properly sealed. This requirement is restated from the last inspection. The previous timescale was 31/7/05. The registered person must ensure that a resident’s bedroom is redecorated. The registered person must ensure that all toilet roll holders are replaced. Timescale for action 30/11/05 2 12(3) 30/11/05 3 YA19 12(1)(a) 30/11/05 4 YA24 23(2)(b) 31/12/05 5 6 YA24 YA24 23(2)(b) 23(2)(b) 31/01/06 30/11/05 Shenley Lodge DS0000010680.V251150.R01.S.doc Version 5.0 Page 21 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.V251150.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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