Inspection on 08/03/06 for Tudor Lodge

This inspection was carried out on 8th March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Tudor Lodge 26/02/07

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 Jane Ray Unannounced Inspection 8 March 2006 09:15 Tudor Lodge DS0000010541.V271214.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 Tudor Lodge DS0000010541.V271214.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. Tudor Lodge DS0000010541.V271214.R01.S.doc Version 5.0 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.V271214.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th July 2005 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. Tudor Lodge DS0000010541.V271214.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on 8 March 2006 and was unannounced. The inspection lasted for two hours. The inspector was able to meet four of the service users, the manager and a member of staff. The inspector spoke at length with two of the service users. The manager was very helpful throughout the inspection. The inspector toured the communal areas of the home and also looked at relevant records. What the service does well: What has improved since the last inspection? 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. Tudor Lodge DS0000010541.V271214.R01.S.doc Version 5.0 Page 6 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.V271214.R01.S.doc Version 5.0 Page 7 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): These standards were not inspected on this occasion as there had been no new service users admitted to the home. EVIDENCE: Tudor Lodge DS0000010541.V271214.R01.S.doc Version 5.0 Page 8 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): 6,8 and 9 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 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 has now been recorded on the service user’s care plan. Tudor Lodge DS0000010541.V271214.R01.S.doc Version 5.0 Page 9 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.V271214.R01.S.doc Version 5.0 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 the following standard(s): 12,13 and 15 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. EVIDENCE: At the time of the inspection four 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 the previous day he had been out shopping with the staff from the home. The residents also said that they enjoyed occasional social activities with the home including pub trips and day outings. 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 three 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. Tudor Lodge DS0000010541.V271214.R01.S.doc Version 5.0 Page 11 The residents 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. Tudor Lodge DS0000010541.V271214.R01.S.doc Version 5.0 Page 12 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 and 20 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: 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. 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 and homely remedies. Tudor Lodge DS0000010541.V271214.R01.S.doc Version 5.0 Page 13 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): 23 The staff have received training on adult protection procedures and have the knowledge to respond appropriately to an allegation of abuse. The recording of how residents spend their money where they are supported by staff in the home needs to be improved to ensure the residents finances are safeguarded. EVIDENCE: The training records for all the staff were inspected. This showed that in the previous year they have all received training on adult protection procedures. 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 one week this was £40 and most of this was given directly to the service user but there was no record of how this money was actually used. Tudor Lodge DS0000010541.V271214.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Service users 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. The manager explained that she plans to replace the carpet in the communal hallways later in the year. Tudor Lodge DS0000010541.V271214.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 and 36 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: The rota for the home was inspected and this showed that there are two staff working during the day 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 six care staff working in the home and four have got an NVQ level 2 or 3 in care. One other carer is studying for an NVQ level 2. This means that more than 50 of the staff have the necessary NVQ qualification. 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. Tudor Lodge DS0000010541.V271214.R01.S.doc Version 5.0 Page 16 All the staff have a completed induction training record and the home has adopted a format based on the TOPPS training. The training records also show that ongoing training is booked as required. All the staff had supervision records and an annual appraisal. The supervision has been taking place four times a year rather than the six times recommended by the National Minimum Standards for Younger Adults. Tudor Lodge DS0000010541.V271214.R01.S.doc Version 5.0 Page 17 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): 42 Health and safety procedures are in place in the home but two staff members need first aid training or for this training to be updated. Some staff also need other health and safety training to be updated. EVIDENCE: The fire safety records were inspected and fortnightly fire alarm checks, six monthly drills and three monthly staff fire training are taking place. In addition the home has a comprehensive fire safety risk assessment. The portable electrical appliance check certificate was inspected and the appliances have all been checked in the last 12 months. The staff training records were inspected. One member of the night staff had not had first aid training and as they work on their own at night this training needs to be completed. One other member of staff had first aid training but this had been completed nearly six years ago and needs to be repeated. All the staff have had food hygiene and health and safety training but for two Tudor Lodge DS0000010541.V271214.R01.S.doc Version 5.0 Page 18 members of staff the food hygiene training needs to be refreshed as it had taken place over four years ago. Tudor Lodge DS0000010541.V271214.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 x Standard No 22 23 Score x 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 x 3 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 x 17 Standard No 31 32 33 34 35 36 Score x 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Tudor Lodge Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score x x x x x 1 x DS0000010541.V271214.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? NO 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 YA23 Regulation 13(6) Requirement The registered person must ensure that where a service user is supported by staff to manage their money, that the records clearly show how the service user is using the money that is withdrawn from their account. The registered person must ensure that night staff have completed their first aid training and that other staff with first aid training have this updated. The registered person must ensure that staff have their food hygiene training updated. Timescale for action 31/03/06 2 YA42 13(4) 30/04/06 3 YA42 13(3) 30/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA36 Good Practice Recommendations The registered manager should support the staff to be supervised six times a year. Tudor Lodge DS0000010541.V271214.R01.S.doc Version 5.0 Page 21 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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