Inspection on 11/05/06 for Unique Lodge

This inspection was carried out on 11th May 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Unique Lodge 08/07/09

Unique Lodge 16/07/07

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 Unique Lodge 8 Llanthony Road Morden Surrey SM4 6DX Lead Inspector Adrian Gordon Announced Inspection 11th May 2006 10:30 Unique Lodge DS0000065479.V295836.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 Unique Lodge DS0000065479.V295836.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. Unique Lodge DS0000065479.V295836.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Unique Lodge Address 8 Llanthony Road Morden Surrey SM4 6DX 020 8648 3871 020 8648 3728 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 Grace Aghoghovbia Miss Ayra Clemence Ablavi Care Home 4 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (4) of places Unique Lodge DS0000065479.V295836.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection No previous inspection. Unique Lodge was registered on 30/11/05. Brief Description of the Service: Unique Lodge is registered with the CSCI to accommodate a maximum of four adults with mental health problems. The home is located in a residential road in Morden and is in keeping with neighbouring homes. It is situated close to bus routes and local amenities at Morden and Sutton. Accommodation is provided over three floors and includes a lounge, kitchen/dining area, bathroom and separate shower area. There is a paved area to the rear of the property. The home is staffed twenty four hours a day. Information about the service is available in the Statement of Purpose and Service User Guide. Unique Lodge charges fees which range from £650 to £950. There are no additional charges. Unique Lodge DS0000065479.V295836.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced 48 hours prior to the visit and was completed over the course of one day by one inspector. The inspection consisted of examination of records, inspection of communal areas, observation of care practice, talking to residents, staff and the registered manager. Two members of staff were able to give feedback. Attempts were made to contact the placing authority but there has been no response. What the service does well: What has improved since the last inspection? What they could do better: The home must ensure that the health, safety and welfare of residents is better protected. Medication must be labelled with the correct dose. Environmental risks must be dealt with immediately, for example the broken light in the shower room. A record of resident money must be maintained accurately. Staff recruitment files must contain all the necessary information. Serious incidents and accidents must be reported to the Commission. The home must obtain a copy of the London Borough of Merton’s Protection of Vulnerable Adults procedures. Unique Lodge DS0000065479.V295836.R01.S.doc Version 5.2 Page 6 Staff must receive specialist training in the field of mental health in order to have a better understanding of residents needs. 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. Unique Lodge DS0000065479.V295836.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 Unique Lodge DS0000065479.V295836.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents are able to make an informed choice about the suitability of the home. EVIDENCE: The Statement of Purpose is of a good standard and gives a clear picture of the service the home provides. New residents are given a Service User Induction Guide which includes information about how to complain, awareness of abuse, keyworker system and the resident support plan. The guide gives new residents a good picture of what to expect at the home. One resident confirmed she had been given a copy of the guide, although only recently. Resident files contained an application and referral form, needs assessment and Personal Development Plan. All documents have been signed and agreed by the resident. A resident showed me a copy of the Care Plan received from the Community Mental Health Team but commented that the type was too small too read. Copies of the contract, terms and conditions and tenancy agreement were also kept on file. These had been signed by the resident, manager and care manager. The contract contains all the required information. One resident was unsure whether they had received a copy of the contract. Unique Lodge DS0000065479.V295836.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Good care planning information supports residents in meeting their personal goals. EVIDENCE: One resident file contained a needs assessments and care plan which had been reviewed and updated as required. There was good examples of residents being involved in decisions. A support agreement had been signed by the service user and a progress report dated 7/11/05 was on file which sets new goals and includes comments and signature from the resident. One to one meetings take place monthly and records are kept on file. Risk assessments were seen to be in place, including a risk management plan. Staff on duty stated that residents are supported to take risks but that they always try to explain the possible consequences, for example, working with a resident to manage their budget more effectively. One resident confirmed that Unique Lodge DS0000065479.V295836.R01.S.doc Version 5.2 Page 10 they were able to make their own decisions but would ask for staff support if needed. Unique Lodge DS0000065479.V295836.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents have the opportunity to take part in appropriate activities and are supported to take responsibility for their daily lives. EVIDENCE: One resident confirmed that they can choose which activities they want to do, for example the cinema or shopping and that they make use of local buses. The resident also confirmed that relatives are able to visit when they want. Opportunities are made available to take part in community activities but staff respect the residents right to choose if they want to take part. One resident said that they help to do a food shopping list and then go out to buy this with their keyworker. The resident is then able to choose what they want to eat at mealtimes. Staff try to encourage healthy eating and this is noted in the care plan but, as confirmed by the resident, the final choice is theirs. Unique Lodge DS0000065479.V295836.R01.S.doc Version 5.2 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): 18, 19, 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Support is in place to meet health needs but medication systems must be improved in order to protect residents. EVIDENCE: Staff were observed to treat residents with respect and it was clear that residents are able to make choices and decisions about how they prefer to live. For example, one resident chose to stay in bed late and staff were seen to respect this on the day of inspection. One resident also stated that they have choice over what they eat. The staff team reflects the cultural background of residents. Care plans contain details regarding health needs and risk assessments are in place regarding health care. Residents are registered with a doctor and receive support from the local Community Mental Health Team. Medication policies and procedures are of a good standard and staff are trained in administration of medication when they start at the home. This was confirmed by a member of staff. There is a sheet in the medication file which staff sign to confirm they have read the procedures. One resident profile did Unique Lodge DS0000065479.V295836.R01.S.doc Version 5.2 Page 13 not have a photograph of the resident and a recent change in medication had not been noted. This was done by the manager during the inspection. Medication is administered from its original container, however labels were not always specific and two containers stated ‘as directed’. In order to safeguard residents the home must ensure that medication received from the pharmacist is labelled accurately. Unique Lodge DS0000065479.V295836.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Appropriate policies and procedures are in place to prevent abuse, however the home must ensure these are carried out in practice. EVIDENCE: The manager said there had been one informal complaint since the home was registered. This was dealt with appropriately. Residents are made aware of the complaints procedure during their admission. It is also clearly explained in the Service User Guide. One resident stated that they would speak to their keyworker or the manager if they were concerned about anything. The resident also said that they had recently complained about a broken light in the bathroom but that it was still not mended. This was checked and the light found to be faulty. This made it risky for the resident to have a shower as the room was too dark. The home must take immediate action when concerns such as this are raised. The home has policies and procedures for the protection of vulnerable adults (POVA) but must get a copy of the London Borough of Merton’s local procedures. The manager stated that POVA training has been booked for all staff on 9/06/06. This will help ensure that residents are protected. Staff confirmed that they were aware of the whistleblowing process. Unique Lodge DS0000065479.V295836.R01.S.doc Version 5.2 Page 15 The home keeps small amounts of money on behalf of residents which are stored in a safe. A record of one residents finance was confusing because receipts were mixed up. The amount of cash found to be 4p short. In order to prevent financial errors, the home must develop a better system for storing receipts and recording money taken in and out. This must be checked at least weekly by the manager. One resident confirmed that they have money when they need it. Unique Lodge DS0000065479.V295836.R01.S.doc Version 5.2 Page 16 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, 28, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents benefit from living in a clean, comfortable environment which meets their needs. EVIDENCE: Unique Lodge is laid out over three floors. All corridors were seen to be clean and tidy but would benefit from the addition of pictures to make them more homely. The kitchen was domestic in feel with a large wooden table for communal meals. Residents are given their own cupboard for personal food items. To the rear is a paved garden area with a table and chairs. One resident said that they use this area to smoke but would like it if there were more plants. Residents can make use of a lounge on the ground floor and toilet, showers, and baths are sufficient in number. There is a room on the first floor which is available for meetings if needed. Unique Lodge DS0000065479.V295836.R01.S.doc Version 5.2 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): 32, 34, 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. To ensure that resident needs are fully understood staff must have access to specialist mental health training. EVIDENCE: Recruitment policies and procedures are of a good standard. Staff files contained most of the information needed to ensure recruitment protected residents. This included two references, Criminal Records Bureau Disclosure, copy of passport, signed contract and job description. However, no files had a photograph of the staff member or a copy of their birth certificate. Records showed that after starting at the home, staff receive induction training in line with Skills for Care guidelines. An induction handbook is also given to staff when they start. One member of staff stated that they felt well supported during this time. Supervision records show that this takes place about once a month. However, a better system of recording must be developed by the manager. Appraisals are also taking place as necessary. Staff on duty confirmed that they feel supported in their role and enjoy working at the home. Two members of staff have said they are currently doing NVQ training to Level 2. A range of basic Unique Lodge DS0000065479.V295836.R01.S.doc Version 5.2 Page 18 training is available to staff but specialised training is limited. In order to develop staff skills in the field of mental health, there must a formal training programme in place. Unique Lodge DS0000065479.V295836.R01.S.doc Version 5.2 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents benefit from a competent manager. Monitoring systems must be improved in order to ensure residents welfare is promoted. EVIDENCE: The manager has the necessary experience to run the home and was registered with the CSCI in November 2005 and is currently completing the Registered Managers Award. The manager confirmed that she meets with the provider regularly and is well supported. Although the provider visits the home about once a month, mostly unannounced, monthly monitoring reports are not completed. These must be done and a copy forwarded to the local CSCI office. A Business Plan for 2005-8 sets quality standards for the home. The manager and staff said that resident feedback is gained on a daily basis, but because of the current low number of Unique Lodge DS0000065479.V295836.R01.S.doc Version 5.2 Page 20 residents there have been no formal surveys yet. A resident confirmed that she regularly talks to a keyworker ‘who understands me’. The manager said that quality assurance reviews are sent to the Community Mental Health Team every 6 months. Details of incidents and accidents are recorded properly but the CSCI has not been notified of any of the five incidents which occurred since August 2005. Procedures must be put in place to ensure that this happens. Records are kept of health and safety checks on the building. Risk assessments are of a good standard and have been reviewed as necessary. The gas safety check is overdue and Control of Substances Hazardous to Health (COSHH) information needed updating. All other checks have been carried out at the required interval. Fire procedures and systems are clear and notices are properly placed around the house. Records showed the alarm is tested weekly and fire drills take place every month. Unique Lodge DS0000065479.V295836.R01.S.doc Version 5.2 Page 21 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 3 2 2 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 2 X Unique Lodge DS0000065479.V295836.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? N/A 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 YA2 Regulation 14(1) Requirement The registered person must ensure that the Care Management assessment and care plan is in a format that can be understood by residents. The registered person must ensure that changes in medication are recorded on administration records and that labels on medication accurately reflect the dosage. The registered person must ensure that medication profiles have a photograph of the resident. The registered person must ensure that concerns raised by residents that affect their safety are acted on immediately. The registered person must obtain a copy of the London Borough of Merton’s POVA procedures and ensure that staff are made aware of the contents. The registered person must ensure that a record of resident money is maintained accurately. The registered person must ensure that staff files contain the information required. DS0000065479.V295836.R01.S.doc Timescale for action 01/07/06 2 YA20 13(2) 05/06/06 3 YA20 13(2) 05/06/06 4 YA23 4(a) 05/06/06 5 YA23 13(6) 01/07/06 6 7 YA23 YA34 17(2), Schedule 4(9) Schedule 2 05/06/06 01/07/06 Unique Lodge Version 5.2 Page 23 8 9 YA35 YA39 18(c)(i) 26 10 YA42 37(e) 11 YA42 13(4) The registered person must ensure that staff receive training in the field of mental health. The registered person must ensure that monthly monitoring visits take place and that a report of the visit is sent to the local CSCI office. The registered person must notify the Commission of any event in the home which adversely affects the well being of residents. The registered person must ensure that a gas safety check is carried out and that Control of Substances Hazardous to Health information is updated. 01/08/06 01/07/06 01/07/06 01/07/06 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 YA24 Good Practice Recommendations The registered person should consider the use of pictures in corridors and plants in the rear patio area. Unique Lodge DS0000065479.V295836.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG 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 Unique Lodge DS0000065479.V295836.R01.S.doc Version 5.2 Page 25 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!