Inspection on 26/02/07 for Tudor Lodge

This inspection was carried out on 26th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Tudor Lodge 08/03/06

Tudor Lodge 14/01/05

Tudor Lodge 14/10/04

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

Ashwood House (Leyton)

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

CARE HOME ADULTS 18-65 Tudor Lodge 164 Green Lane Edgware Middlesex HA8 8ET Lead Inspector Mr David Hastings Key Unannounced Inspection 26th February 2007 09:30 Tudor Lodge DS0000010541.V323107.R01.S.doc Version 5.2 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 Tudor Lodge DS0000010541.V323107.R01.S.doc Version 5.2 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. Tudor Lodge DS0000010541.V323107.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tudor Lodge Address 164 Green Lane Edgware Middlesex HA8 8ET 020 8958 9932 020 8958 9670 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) Mrs Anjalee Bhurton Mrs Anjalee Bhurton Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5) of places Tudor Lodge DS0000010541.V323107.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th March 2006 Brief Description of the Service: Tudor Lodge is a residential care home providing personal care for five younger adults with a diagnosis of mental disorder. The home is privately owned with the registered manager also being the registered provider. The home is a large converted two-storey, detached domestic house that is very well decorated and maintained. The ground floor contains the communal lounge, kitchen/ diner, one service user bedroom and a separate toilet. The first floor contains the other four service user bedrooms, one of which has ensuite shower facilities, a bathroom/ toilet and staff facilities/ registered managers office. There is a large attractive garden to the rear. The home has a range of additional handrails on the stairs and in the bathroom although is not suitable for service users with a significant physical disability. The home is situated in a quiet and attractive residential area of North London and is located within convenient travelling distance to both public transport and the major road network to central London and the M25 motorway. The stated objective of the home is to provide care to all service users to a standard of excellence that embraces fundamental principles of good care practice. It also aims to provide its service users with a secure, relaxed and homely environment in which their care, well being and comfort is of prime importance. The current scale of charges are £560 - £774 per week. A copy of this report is available on the CSCI website or/and from the home. Tudor Lodge DS0000010541.V323107.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on Monday 26th February 2007 and lasted three hours. The inspector was able to meet three of the service users, the manager and a member of staff. The manager was very helpful throughout the inspection. The inspector toured the communal areas of the home and also looked at relevant records. Prior to this inspection four comment cards were sent to the CSCI from service users and one comment card from a care manager. These were all very positive about the care and support provided by the home. The service users informed the inspector that they were well looked after at the home. What the service does well: What has improved since the last inspection? What they could do better: As a result of this inspection one requirement and one recommendation has been made. The requirement is related to quality monitoring at the home. The new recommendation is related to staff training in mental health issues. The inspector is confident that the manager will comply with the requirement and recommendation within the timescale given. Tudor Lodge DS0000010541.V323107.R01.S.doc Version 5.2 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Tudor Lodge DS0000010541.V323107.R01.S.doc Version 5.2 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 Tudor Lodge DS0000010541.V323107.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager ensures that detailed assessments are carried out on all prospective service users moving in to the home. EVIDENCE: At the time of the inspection there were four service users residing at the home. There is one vacancy. Although no new service users have been admitted since the last inspection, evidence gained at previous inspections indicates that service user’s individual aspirations and needs have been appropriately assessed. The manager was very clear that the vacant place would only be filled by someone who had a detailed assessment and whose needs would be able to be met by the home. Tudor Lodge DS0000010541.V323107.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users’ assessed and changing needs and personal goals are clearly reflected in their individual care plans. Service users are able to make decisions about their lives with support from staff and they are able to take risks as part of an independent lifestyle. These risks are recorded and the staff ensure that these risks are minimised as far as possible. EVIDENCE: There was a satisfactory and detailed service user plan on each service user file inspected that was informed by appropriate risk assessments and other assessment material. Both the service user and the registered manager had signed the plans. One service user has a history of wandering from the home at night. As a result of this the registered manager stated that a decision had been agreed between the home, placing authority and the service user that their movements would be monitored and agreement reached about when was an appropriate timescale for seeking help from the emergency services if the Tudor Lodge DS0000010541.V323107.R01.S.doc Version 5.2 Page 10 service user did not return home. This was agreed as a mechanism to reduce the risk of the person coming to harm when out of the home. This decision is recorded on the service user’s care plan and updated regularly. The manager stated that this situation occurs far less frequently now. The service users all said they felt able to speak to staff about their wishes in the home. They also said they enjoyed the community house meetings and felt this was a good occasion to discuss issues relating to the home. The record of this meeting was inspected and they are taking place once a month and offered the service users an opportunity to discuss issues relating to the home such as domestic chores, food and outings. Tudor Lodge DS0000010541.V323107.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are supported to be part of the local community and to participate in activities relating to their culture and religion. They are also able to maintain relationships with families and friends. This enables the service users to have a fulfilling lifestyle. Service users rights are respected and they are offered a healthy diet and enjoy their meals and mealtimes. EVIDENCE: At the time of the inspection three of the service users were going out to different community based activities including college, supported employment and a drop in service. One service had chosen to stay at home but said that he was happy with the activities available to him both inside and outside the home. The service users also said that they enjoyed occasional social activities with the home including pub trips and day outings. Tudor Lodge DS0000010541.V323107.R01.S.doc Version 5.2 Page 12 The service users have diverse cultural and religious backgrounds and two were able to say how they chose to follow their religion. The manager also explained that two of the service users choose to go to their place of worship on a regular basis. In addition their different dietary needs are met within the home. The staff member explained to the inspector that she asks what service users would like to eat each day. The kitchen was clean and contained the required equipment. Service users said they enjoyed the meals at the home. The service users were able to say how they see family and friends and they are welcome in the home if they want to come for a visit. Service users said their rights were respected and clear examples of how service users’ rights are respected were detailed in individual care plans. Tudor Lodge DS0000010541.V323107.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are treated with respect and their right to privacy is upheld. The service users are supported to access healthcare services and the medication in the home is administered correctly, which enables the service users to maintain good health. EVIDENCE: Service users that the inspector met said they liked the manager and staff at the home and that they were treated with respect when assisted with personal support. The service users spoken to said that they go to the doctor, optician and dentist on a regular basis. The manager also explained that the residents are supported to access specialist mental health services and other healthcare appointments, as required. Further evidence in individual care plans indicated that service users have good assess to health care professionals. The medication records were inspected. These all showed the medication received by the home and the administration records were correctly signed. A record is also kept of medication returned to the pharmacist. Tudor Lodge DS0000010541.V323107.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Complaints are taken seriously and dealt with appropriately and openly by the manager. The staff have received training on adult protection procedures and have the knowledge to respond appropriately to an allegation of abuse. EVIDENCE: The record of complaints was examined. There had been two minor complaints since the last inspection. These complaints had been dealt with in a through and detailed manner and indicated the outcome of the investigation. Service users said they had no complaints about the service but knew what to do if they did have. The training records for all the staff were inspected. This showed that they have all received training on adult protection procedures. The manager was clear about her responsibilities in reporting any suspicion or allegation of abuse to the appropriate authorities. One resident is supported by staff in the home to manage their finances. The reasons for this are recorded in the care plan and risk assessment. The records for these finances were inspected and showed that the resident was supported to withdraw money once a week from his account and some is given to him and the rest is held in the office to be used gradually throughout the week. The amount withdrawn can vary and most of this was given directly to the service user. The accounts of this spending were clearly recorded and detailed how the money was spent with receipts and bank statements attached. This was a requirement from the last inspection that has now been complied with. Tudor Lodge DS0000010541.V323107.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users live in a homely, clean, comfortable and safe environment, which is decorated and maintained to a high standard. EVIDENCE: The premises have been converted from a family home to a very high standard. The physical environment is well decorated and maintained and provides a pleasant and comfortable environment for both service users and staff. The home is situated in a quiet residential area of North London with access to public transport. The premises were seen to be bright, cheerful, airy, clean and free from offensive odour and met the requirements of this standard. Tudor Lodge DS0000010541.V323107.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users are supported by a staff team, who are stable and well trained and who understand the needs of the service users at the home. EVIDENCE: On the day of the inspection one support worker and the manager were on duty. One member of staff has recently left the home and the manager is in the process of recruiting a new member of staff. There are only four service users residing at the home. Service users said they felt supported by the staff and manager of the home. The rota for the home was inspected and this showed that there are two staff working during the day (including the manager) and one waking member of staff at night. The manager explained that she is on call at night in case she is needed to give assistance. The manager explained that the staff team has a very low turnover and most of the staff have worked at the home since it opened. There are five care staff working in the home and all staff have got an NVQ level 2 or 3 in care. This exceeds the requirements of this standard. Tudor Lodge DS0000010541.V323107.R01.S.doc Version 5.2 Page 17 The record of staff meetings was inspected. These take place each month and include discussing the service users and any changes in the service as well as training issues. The staff records were inspected and all the staff had the necessary recruitment checks including a CRB disclosure, ID and two written references. All the staff have a completed induction training record and the home has adopted a format based on the Skills For Care training. The training records also show that ongoing training is booked as required. Although there was evidence that staff undertake a satisfactory level of training, staff have not actually attended courses relating to mental health issues. A good practice recommendation has been issued that staff attend training specifically relating to mental health. This should give the staff the underpinning knowledge needed to better understand the issues faced by people with mental health problems. All the staff had supervision records and an annual appraisal. Records indicated that staff supervision has been taking place every two months. This was a good practice recommendation, issued at the last inspection that has now been complied with. Tudor Lodge DS0000010541.V323107.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well run by a committed and competent manager. There are good systems in place to measure the quality of care provision. There are good systems in place to monitor health and safety compliance and staff receive the health and safety training they need to ensure the safety of service users. EVIDENCE: Feedback received from both staff and service users was very positive about the manager and the way the home is run. The manager has undertaken the training required to meet this standard. The manager has recently purchased a quality monitoring tool and intends to carry out a self monitoring assessment of the home. There are good systems in Tudor Lodge DS0000010541.V323107.R01.S.doc Version 5.2 Page 19 place to monitor quality of care including service user questionnaires. However to fully meet this standard the manager must ensure that the results of any quality monitoring findings are published and made available to service users and their representatives. A requirement relating to this has been made in the relevant section of this report. Records in relation to health and safety were examined. Fire safety records indicated that fire alarm checks, six monthly fire drills are taking place. The home has fire safety risk assessments and the local fire officer visited the home on 23/05/06. No recommendations were issued at that inspection. Satisfactory records were seen in connection with fire alarm tests, fire extinguisher servicing, emergency lighting checks, gas safety, electrical installation and Legionella tests. All staff, where applicable, have completed or updated their training in food hygiene and first aid. These were two requirements, issued at the last inspection that have now both been complied with. Tudor Lodge DS0000010541.V323107.R01.S.doc Version 5.2 Page 20 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 X 2 3 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 4 23 4 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 4 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 4 X 4 X 2 X X 3 X Tudor Lodge DS0000010541.V323107.R01.S.doc Version 5.2 Page 21 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 YA39 Regulation 24(2) Requirement The registered manager must ensure that the results of any quality monitoring findings are published and made available to service users and their representatives. Timescale for action 01/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA35 Good Practice Recommendations The registered manager should ensure that staff attend training specifically relating to mental health. This should give the staff the underpinning knowledge needed to better understand the issues faced by people with mental health problems. Tudor Lodge DS0000010541.V323107.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Tudor Lodge DS0000010541.V323107.R01.S.doc Version 5.2 Page 23 - 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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