Inspection on 17/05/05 for Shenley Lodge

This inspection was carried out on 17th May 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Shenley Lodge 07/08/07

Shenley Lodge 10/04/06

Shenley Lodge 11/10/05

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 Bush Hill Park Enfield, Middlesex EN1 2QN Lead Inspector Tom McKervey Unannounced 17 May 2005 @ 09.30am 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. SHENLEY LODGE Version 1.10 Page 3 SERVICE INFORMATION Name of service Shenley Lodge Address 34 Abbey Road, Bush Hill Park, Enfield, Middlesex EN1 2QN 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) 020 8363 1173 Vijaye Koomar Kowlessur Vijaye Koomar Kowlessur PC Care Home only 7 Category(ies) of LD Learning Disability registration, with number of places SHENLEY LODGE Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: 1 Two specified service users who are over 65 years of age may remain accommodated in the home. 2 The home must advise the regulating authority at such times as either of the specified service users vacates the home. 3 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. Date of last inspection 12 August 2004 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 service users. The home is close to shops and amenites and there are good public transport links. A minibus is available for taking service users to day centres and other activities in the community. SHENLEY LODGE Version 1.10 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 service users living in the home. One person had recently been admitted for assessment, and there was one vacancy for the double room. This vacancy occurred following the death in hospital of a service user in March 2005. The inspector wishes to thank the manager and deputy, who were both present, for their assistance with the inspection. A tour of the premises was carried out, and service users’ records and documents relating to the running of the home, were examined. Two service users and the deputy manager were spoken to independently. There were no visitors to the home during the inspection. The inspector was satisfied that the home was well run and that the quality of the care and the environment were good. What the service does well: What has improved since the last inspection? At the last inspection, eight requirements were made, all of which had been complied with satisfactorily. These were specifically about; Service users being involved in drawing up care plans. Provision of an occupational therapist assessment for a specific service user. Ensuring satisfactory staffing levels. SHENLEY LODGE Version 1.10 Page 6 Five other requirements were made to address medication issues. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. SHENLEY LODGE Version 1.10 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 SHENLEY LODGE Version 1.10 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) 2 Very positive relationships have been formed between the service users and the staff, which, together with well-documented assessments, provide the basis for a good understanding of service users’ needs. EVIDENCE: The case files of a new service user were examined. At the time of the inspection, this person had only been living at the home for three weeks and was being assessed regarding the home’s ability to meet his needs. There was evidence that the service user’s social worker, and a psychologist were involved in this process, jointly with the home. Another service user’s records showed that he had been assessed by an occupational therapist regarding his blindness. The report indicated that his needs were being met by the home. The inspector had a discussion with this service user and was satisfied that he was happy to live in the home and that he was well cared for. SHENLEY LODGE Version 1.10 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 & 9 Guidance for staff about meeting new service users’ needs was not being provided due to unacceptable delays in compiling care plans. EVIDENCE: The new service user did not have a care plan. The inspector was informed that this was because the home was waiting for a care plan from the occupational therapist. This is not acceptable. A requirement was made for a care plan to be provided for this specific service user, based on the assessments already available, including the home’s own assessment. A discussion with one service user who had verbal skills, indicated that he was able to choose various activities, his meals and time of going to bed. The inspector saw in the records of the new service user, who had limited verbal communication, that he indicated his preferences when given a range of options. There were good risk assessments in place in the service users’ records, regarding activities inside and outside the home. SHENLEY LODGE Version 1.10 Page 10 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) 12, 13, 14, 15 & 17 Service users’ enjoy a good quality of life, which maximises their potential. Service users are well supported to integrate with the local community. EVIDENCE: The records showed that five of the service users attend day centres at various times during the week. The daily records contained evidence of service users going out for meals at pubs and restaurants, and attending church services. One service user was supported by a member of staff going out for a walk during the inspection. A service user informed the inspector that he enjoyed listening to tapes and cd’s. There was evidence that all the service users had a holiday last year, and another was planned to take place this summer. The visitors’ book showed that there were frequent visits to the home by relatives and friends. An advocate for one service user visits him twice a week. The menus showed that choice of meal was offered. The fridge and freezer contained ample quantities of food, and there was fresh fruit available. SHENLEY LODGE Version 1.10 Page 11 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, 19 & 20 The healthcare needs of service users are being met with the support of the G.P and community learning disability team. There is a safe system for the administration of medicines. EVIDENCE: There were records of appointments with G.P’s, including general check-ups. Service users receive input from professionals in the Community Learning Disability Team. There were records of service users’ weights being monitored monthly. The medication policy now includes, a statement about covert administration of medicines, consent from service users, and a list of homely remedies. Approval from G.P’s.for these was obtained. PRN medication was appropriately recorded. SHENLEY LODGE Version 1.10 Page 12 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 & 23 Service users are safeguarded from potential abuse through appropriate procedures and staff training. EVIDENCE: The home has a complaints procedure, which meets the standard. The service user who was spoken to, stated that he had no complaints and that the care he received was good. However, he described what action to take if he needed to complain. The last recorded complaint was in 2001. There were adult protection procedures in place, and staff records showed that they had attended training in this subject in April 2004. SHENLEY LODGE Version 1.10 Page 13 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, 25, 26 27 28 & 30. The overall standard of the environment is pleasing, homely and comfortable. However, one bathroom is in need of redecoration, and the poor state of the laundry floor could present a health and safety hazard and structural damage to the building. EVIDENCE: A tour of the interior and exterior of the premises was carried out. The standard of décor in the home was very good, and this was a good environment to meet service users’ needs. 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 both toilets. The floor covering in the laundry was torn in places. All the bedrooms were visited and they were well furnished, with evidence of personal belongings. At the time of the inspection, the home was clean and tidy and there were no offensive odours. SHENLEY LODGE Version 1.10 Page 14 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) 32, 33, 34 & 35 There are sufficient staff on duty, and appropriate training and supervision is provided to meet service users’ needs. However, service users could be placed at risk from unsatisfactory recruitment practices. EVIDENCE: Staff records confirmed that the service users are supported by staff who have attended appropriate training courses, including NVQ’s. The staff rotas showed that there are normally three staff on duty, first thing in the morning, and two from 9am till 8.30 pm. One staff sleeps-in at night. The manager’s duties were also recorded on the rota. Two staff records were sampled. In one case, a staff member had an old CRB certificate, which they had brought with them from a previous employer, and a new one had not been obtained. Staff records showed that they receive supervision at least six times per year. SHENLEY LODGE Version 1.10 Page 15 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, 39 & 42. The home is generally well run, with good leadership provided for the staff. Service users’ and other stakeholders’ views are sought to enable the development of the service. The safety of service users, staff and visitors to the home is being compromised by not having fire extinguishers tested annually. EVIDENCE: The deputy manager was spoken to. He stated that the manager provides leadership through good communications and his regular presence. The inspector saw a quality assurance audit which canvassed service users’ and other stakeholders’ views about the service, which were positive on the whole. There were records to show that fridge and freezer temperatures were recorded daily and fire alarms were tested regularly. However, the inspector made an immediate requirement for the fire extinguishers to be serviced, as the service date had expired. SHENLEY LODGE Version 1.10 Page 16 COSHH materials were securely stored. 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 2 3 x 3 Standard No 11 x Standard No 31 32 33 Score x 3 3 Page 17 SHENLEY LODGE Version 1.10 12 13 14 15 16 17 3 3 3 3 x 3 34 35 36 2 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x 3 3 x x 2 x SHENLEY LODGE Version 1.10 Page 18 No 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 6 Regulation 15(1) Requirement The registered person must ensure that a care plan is provided for new service users service useres within 24 hours of admission to the home. The registered person must ensure that the covering on the laundry floor is repoaced with a non-permeable material and properly sealed. The registered person must ensure that the first floor bathroom is redecorated and the toilet roll holders are replaced. The registered person must ensure that a new CRB/POVA check is obtained for all newly recruited staff before they start work at the home. The registered person must ensure that the fire extinguishers are tested annually. This is an immediate requirement. Timescale for action 30/6/05 2. 24 23(2)(b) 31/7/05 3. 27 23(2)(d) 31/7/05 4. 34 7,9,19 30/6/05 5. 42 13(4)(c) 24/5/05 SHENLEY LODGE Version 1.10 Page 19 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. 2. Refer to Standard Good Practice Recommendations SHENLEY LODGE Version 1.10 Page 20 Commission for Social Care Inspection 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 Version 1.10 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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