Inspection on 06/06/05 for White Moon Lodge

This inspection was carried out on 6th June 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

White Moon Lodge 22/01/07

White Moon Lodge 13/02/06

White Moon Lodge 16/02/05

White Moon Lodge 27/07/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 WHITE MOON LODGE 156 Philip Lane London N15 4JN Lead Inspector Brian Bowie Unannounced 6 June 2005 @ 2:45 pm 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. WHITE MOON LODGE G 59 S10821 White Moon Lodge V224749 06.06.05 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service White Moon Lodge Address 156 Philip Lane, London, N15 4JN 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 8376 4246 Mr Sona Beezadhur Mr Sona Beezadhur PC Care Home 3 Category(ies) of LD registration, with number of places WHITE MOON LODGE G 59 S10821 White Moon Lodge V224749 06.06.05 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16/2/05 Brief Description of the Service: White Moon Lodge is run by Mr Sona Beezadhur who is both the owner and registered manager. It is a small care home for up to three people with learning disabilities. The house is a terraced property situated in a residential area. Upstairs there are three bedrooms for residents and a small office for staff. Downstairs there is a dining kitchen, lounge, bathroom with toilet, shower room and another office that is also used for staff sleeping in. There is a small back garden which residents make use of in warmer weather. The home is close to shops and local facilities. The home provides support to people who have complex needs, including autistic spectrum disorders, and behaviours that can be challenging. There is a minimum of one staff member available throughout the daytime and sleeping in on the premises at night. The home’s aim is to provide as ordinary a life as possible for residents and to encourage them to be as independent as possible. WHITE MOON LODGE G 59 S10821 White Moon Lodge V224749 06.06.05 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over two days and lasted 6 hours. Mr Beezadhur, the owner and manager of White Moon Lodge, was interviewed and helped with the inspection. The home was looked round and two members of care staff were spoken to, with one being interviewed about her role in the home and how she supported the residents. The inspector met all three residents and spoke briefly to them. It was not possible to have any detailed discussion with the residents about their care because of their communication difficulties. The social worker for the three residents was contacted and his view and judgement of the standard of care provided by the home obtained. A variety of records, including careplans and health & safety documents, were looked at. The overall impression from the inspection was of a home that is providing a good standard of care to people with complex needs within a homely and supportive environment. What the service does well: What has improved since the last inspection? The home has obtained additional funding so that it can provide some 1-to-1 support to one of the residents at weekends in order that this individual’s WHITE MOON LODGE G 59 S10821 White Moon Lodge V224749 06.06.05 Stage 4.doc Version 1.30 Page 6 needs can be fully met. Mr Beezadhur has successfully completed the training course which qualifies him as a Registered Manager. At the previous inspection there had been 6 areas which the home had to improve which mainly concerned the living environment within the home. The home had taken action on 2 of these areas. The 4 areas to be done have been outstanding for some time so the home will need to get these attended in the very near future, with one to be dealt with by the end of June 2005. They consist of fitting handbasins in residents’ bedrooms, redecorating and recarpetting these bedrooms, and ensuring the water storage system is serviced. 6 new areas for improvement were identified at this inspection and concern medication arrangements, staff supervision and training, risk assessments, fire drills, and additional staffing. A recommendation to improve practice is made in relation to how medication is given out to residents. Mr Beezadhur emphasised that he is keen to work closely with CSCI to raise standards further at the home in order to be able to provide the best possible quality of life for residents. 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. WHITE MOON LODGE G 59 S10821 White Moon Lodge V224749 06.06.05 Stage 4.doc Version 1.30 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 WHITE MOON LODGE G 59 S10821 White Moon Lodge V224749 06.06.05 Stage 4.doc Version 1.30 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 People moving into the home have their needs and wishes assessed so that the home can be sure that it can meet these needs and wishes. EVIDENCE: The residents indicated by their behaviour and their contact with care staff that they felt relaxed and at home at White Moon Lodge. Each resident had lived at the home for a number of years and was settled at the home. The social worker considered that: ‘The home does a great job with all three service users.’ The case file for each resident was looked at and contained a community care assessment which set out the needs and wishes of each resident. The manager had put together a plan of care setting out how each person’s needs and wishes would be met by the home. WHITE MOON LODGE G 59 S10821 White Moon Lodge V224749 06.06.05 Stage 4.doc Version 1.30 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) 6,9 Residents benefit by having careplans which set out clearly and in detail how their needs and wishes will be met by the home. The home is good at ensuring each resident has detailed risk assessments in place in order to keep them as safe as possible. In order that residents are fully protected risk assessments should be updated following any significant incidents. EVIDENCE: The careplans are detailed and cover all the key aspects of the resident’s life. Arising out of the careplan for each resident there was a daily schedule of activities which the resident liked to take part in. One resident particularly likes to sing songs and a member of staff was observed encouraging the resident to do this. The manager has completed detailed risk assessments for each resident to ensure that any risks identified could be managed by the home. However following a recent significant incident involving one of the residents the risk assessment had not been revised. The home needs to ensure that following any significant incident involving a resident the risk assessment is reviewed to see if it needs to be revised in order to ensure the home is managing the risks involved in the best possible way. WHITE MOON LODGE G 59 S10821 White Moon Lodge V224749 06.06.05 Stage 4.doc Version 1.30 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) 15,17 Residents are getting a better quality of life because of their close contact with friends and family. The home is good at providing meals which the residents enjoy and which ensure they have a healthy diet. EVIDENCE: A member of care staff described the regular contact each resident had with their family. In one case the resident has regular stays at their family home. The social worker for the three residents was spoken to and said the home communicates well with the residents’ families and relatives. In relation to mealtimes a member of care staff said: ‘The residents all eat well, and we watch what they’re eating so that they get a healthy diet.’ The menu was seen and showed that residents were having a variety of healthy meals offered to them. Care staff knew what each resident liked to eat- in one case a resident would point to the cereal packet to indicate which cereal they wanted for breakfast. As a result residents were enjoying the meals provided by the home. WHITE MOON LODGE G 59 S10821 White Moon Lodge V224749 06.06.05 Stage 4.doc Version 1.30 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) 19,20 Staff are good at supporting residents in a way which makes sure their physical and emotional health needs are met. Record-keeping in relation to the administration of medication is not completely accurate so that residents are not fully protected at all times. EVIDENCE: A member of care staff was observed working with one of the residents when they returned from their day centre. The resident was warmly greeted, guided on what they needed to do in terms of taking off their coat and changing into slippers. The resident was clearly pleased to see their careworker and was very relaxed with her. The careworker also went through the person’s communication book so she knew what the person had done at the day centre. As a result the resident got a very personal and supportive approach from the member of staff which ensured the individual’s emotional and physical needs were being met. Careplans were looked at and included the comment from the social worker for one of the residents: ‘I continue to be impressed with the residential service he receives. This service is meeting all his emotional and personal needs.’ Medication arrangements within the home were looked at and in general were satisfactory. However on the day of the inspection there was not a proper record of why a specific tablet was missing from the dosette box used for WHITE MOON LODGE G 59 S10821 White Moon Lodge V224749 06.06.05 Stage 4.doc Version 1.30 Page 12 giving out tablets. It is important that the reasons for any changes in medication administration are clearly recorded. It was noted that there had been a couple of incidents of tablets being dropped whilst being administered. For this reason the recommendation is made again that the home uses blister packs which provide a safer means of giving out medication. The manager said he was planning to introduce this system in the near future. WHITE MOON LODGE G 59 S10821 White Moon Lodge V224749 06.06.05 Stage 4.doc Version 1.30 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 standard(s) 23 The residents benefit from effective adult protection measures which make sure that residents are safe and secure whilst at White Moon Lodge. EVIDENCE: Staff have attended training courses on how to protect vulnerable adults from abuse and know what to do if they think a resident has been the victim of any form of abuse. Following an incident in the home the manager had gone over with staff the adult protection procedures to make very sure staff knew what to do when incidents occur or allegations are made. In one case the home had contributed to a special meeting to look into an incident involving one of the residents. The social worker for the home was spoken to and said that the level of communication by the home with other agencies was ‘exceptional’ compared to other care homes and indicated that he considered White Moon Lodge a safe and supportive environment for the residents. WHITE MOON LODGE G 59 S10821 White Moon Lodge V224749 06.06.05 Stage 4.doc Version 1.30 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 standard(s) 24,26 Residents at White Moon Lodge enjoy an attractive and comfortable living environment which adds considerably to their quality of life. This environment will be improved further once outstanding works are completed. EVIDENCE: White Moon Lodge is homely and comfortable with plenty of space in the downstairs area which enables residents to be on their own, when they want to be, downstairs as well as in their own bedroom. This is particularly helpful for those residents with an autistic spectrum disorder. However certain essential improvements noted at previous inspections had not been followed up. As a result the manager was informed he needed to ensure as a matter of urgency that each of the residents’ bedrooms had its own wash handbasin. Once this work was completed these bedrooms would also need to be redecorated and new carpeting fitted. The manager agreed to get these works carried out within the timescale agreed. WHITE MOON LODGE G 59 S10821 White Moon Lodge V224749 06.06.05 Stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,35,36 Residents benefit from a committed and experienced team of staff who have the skills to meet their needs. However residents do not fully benefit from staff who are regularly guided on how to improve their practice, and who have undertaken training in all essential areas. EVIDENCE: ‘They’ve done a great job with all three residents.’ This was the comment of the social worker for the residents about the staff at the home. A member of care staff was interviewed and said she worked closely with other staff in order to meet the needs of residents. She had also visited the day centre to meet with the keyworker for one of the residents so that the home and the centre could work more closely together. Staff at the home have got to know the needs and wishes of the residents over time and learnt how best to respond to and meet the complex needs of all three residents. As a result residents who previously had had their placements break down because of their challenging behaviours were getting a stable and supportive home to live in. White Moon Lodge has three full time staff with support as needed from the manager. Staff have attended a range of relevant courses but had not always attended courses in areas which were essential if they were to work most effectively with residents. All care staff therefore need to have training in the WHITE MOON LODGE G 59 S10821 White Moon Lodge V224749 06.06.05 Stage 4.doc Version 1.30 Page 16 administration of medication, working with people with challenging behaviours and working with people with autism. The staff files showed that staff are only having one-to-one supervision meetings with the manager now and again, and not on the regular twomonthly basis needed to ensure staff are fully supported and guided on how to improve their practice. The manager must ensure that he supervises all care staff at least two-monthly. The manager agreed to carry out staff supervision at the appropriate frequency level in future. WHITE MOON LODGE G 59 S10821 White Moon Lodge V224749 06.06.05 Stage 4.doc Version 1.30 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 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) 37,42 Residents really benefit from living at White Moon Lodge because the home provides a very personalised service to each of the residents in order to meet their needs. However one specific resident was not getting the level of support he needed to ensure his needs were being met at all times. In general the home is good at making sure the residents are kept safe and secure whilst living at White Moon Lodge. However fire safety and water storage arrangements are not giving the residents the full protection to which they are entitled. EVIDENCE: The manager and staff work closely together to achieve high standards for the home. Feedback from the residents’ social worker was very positive about the way in which the home is run and commented: ‘It’s an excellent care home as far as I’m concerned.’ As a result what the residents get out of the home is a very caring and supportive place to live where they are being helped to get as much as possible out of life. However in one case a resident was not getting WHITE MOON LODGE G 59 S10821 White Moon Lodge V224749 06.06.05 Stage 4.doc Version 1.30 Page 18 the additional 1-to-1 support which his careplan showed was necessary to meet his assessed needs. The manager must ensure this individual gets the level of staffing support indicated in their careplan. A range of records was looked at, including fire safety and accident reports. These records were detailed, up-to-date and accurate and confirmed that the home is being run responsibly with essential checks being made and acted on. However fire drills are only been held twice a year which is insufficient given the needs of the existing group of residents and for all care staff to be familiar with these arrangements. The manager must ensure that fire drills take place at a frequency level which takes account of these factors with a minimum of 4 fire drills each year. As noted at the previous inspection the water storage system needs to be serviced. The manager agreed to have this done following the handbasins being fitted in the residents’ bedrooms. WHITE MOON LODGE G 59 S10821 White Moon Lodge V224749 06.06.05 Stage 4.doc Version 1.30 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 3 x x x Standard No 22 23 ENVIRONMENT Score x 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x 2 x x x x Standard No 11 12 13 14 15 16 17 x x x x 3 x 3 Standard No 31 32 33 34 35 36 Score x x 3 x 2 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 WHITE MOON LODGE Score x 3 2 x Standard No 37 38 39 40 41 42 43 Score 2 x x x x 2 x G 59 S10821 White Moon Lodge V224749 06.06.05 Stage 4.doc Version 1.30 Page 20 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. Standard 9 20 26 Regulation 13 13 23 Requirement Risk assessments to be reviewed following any significant incidents. Changes in the arrangements for giving out medication to be clearly recorded. Wash handbasin to be fitted in each of the residents bedrooms. (Previous timescale of 31/3/05 not met ) Immediate Requirement issued. Residents bedrooms to be redecorated. (Previous timescale of 30/4/05 not met ). Residents bedrooms to have new carpeting. (Previous timescale of 30/4/05 not met). All care staff to have training in the administration of medication, working with people with challenging behaviours and working with people with autism. Timescale for action 30/6/05 30/6/05 30/6/05 4. 26 23 31/7/05 5. 26 16 31/7/05 6. 35 18 31/7/05 7. 8. 36 37 18 12 All care staff to be supervised by 31/7/05 the manager at least twomonthly. The identified resident to get the 31/7/05 level of staffing support indicated in their careplan. G 59 S10821 White Moon Lodge V224749 06.06.05 Stage 4.doc Version 1.30 Page 21 WHITE MOON LODGE 9. 42 13 10. 42 13 Fire drills to take place at appropriate frequency level, with a minimum of 4 fire drills each year. The water storage system to be serviced. (Previous timescale of 30/4/05 not met). 30/6/05 31/7/05 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 20 Good Practice Recommendations The home to use the blister pack system to give out medication. WHITE MOON LODGE G 59 S10821 White Moon Lodge V224749 06.06.05 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection North London 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. Extracts may not be used or reproduced without the express permission of CSCI WHITE MOON LODGE G 59 S10821 White Moon Lodge V224749 06.06.05 Stage 4.doc Version 1.30 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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