Inspection on 03/07/07 for 10, Friday Road

This inspection was carried out on 3rd July 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

10, Friday Road 09/05/06

10, Friday Road 07/11/05

10, Friday Road 06/05/05

10, Friday Road 15/12/04

10, Friday Road 06/07/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Townley Road, 2-3

Orchard House Nursing Home

St Josephs Rest Home

Foxley Lane (121a)

Tudor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE 10, Friday Road Mitcham Surrey CR4 3JQ Lead Inspector Emma Dove Unannounced Inspection 3rd and 6th July 2007 11:30 X10015.doc Version 1.40 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 10, Friday Road DS0000027223.V339122.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 Older People. 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. 10, Friday Road DS0000027223.V339122.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 10, Friday Road Address Mitcham Surrey CR4 3JQ 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) 0208 648 7800 Mr Jose Martin Mrs Sylvia Rookmin Martin Mrs Sylvia Rookmin Martin Care Home 6 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (3), Old age, of places not falling within any other category (6) 10, Friday Road DS0000027223.V339122.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th January 2007 Brief Description of the Service: 10, Friday Road is a registered care home for six older people. This number may include up to three older people with additional mental health needs. Five people are currently living there. Friday Road is owned and managed by two private individuals and is situated in a residential area on the borders of Mitcham and Tooting. Local shops and public transport systems are within a fifteen minute walk. Accommodation is provided over two floors with a double bedroom on the ground floor and four single bedrooms on the first floor. The home is staffed twenty-four hours a day. Basic information about the service is provided to residents in a written brochure, which includes details of the CSCI. The current range of fees are £410.00 to £420.00 per week. 10, Friday Road DS0000027223.V339122.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 over two hours on the 3rd and three hours on the 6th July 2007. One inspector visited and spoke with residents, two visitors, staff and the owner/manager. Records were looked at and the communal areas and four bedrooms were seen. Questionnaires were sent to relatives and professionals and left at the home for residents. Two questionnaires have been received, comments from these are included in the relevant sections of this report. An Annual Quality Assurance Assessment was completed and returned to the CSCI in good time. No other information has been received from the home since the last inspection. What the service does well: What has improved since the last inspection? What they could do better: The hall, lounge and dining room carpet need replacing. Staff files must contain a recent photograph and proof of the individual’s identity. 10, Friday Road DS0000027223.V339122.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. 10, Friday Road DS0000027223.V339122.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection 10, Friday Road DS0000027223.V339122.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 5 People who use this service receive adequate quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The service has developed a brochure which includes information about the home and is used as a Service Users Guide. This brochure provides basic information about the service and is available in standard format. EVIDENCE: A small brochure is available, which provides basic information about the home, facilities, health care, hair care which is an additional fee, communion, staff, visitors and the complaints procedure. People have been living at the home for a number of years and assessments were completed before admission. More information about individuals’ histories has been added to case files since the last inspection. Staff demonstrated detailed knowledge about peoples lives before they moved in. 10, Friday Road DS0000027223.V339122.R01.S.doc Version 5.2 Page 9 The manager reported that information about the service is available to prospective service users and their relatives. Visits to the home and a trial period can be arranged before admission. 10, Friday Road DS0000027223.V339122.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People who use this service receive adequate quality in this outcome area. This judgement has been made using available evidence including a visit to this service. People who use services have access to health care services both within the home and in the local community. The home is generally able to provide aids and equipment recommended, more attention could be given to the changing needs of people who use services. Care plans are in place. EVIDENCE: Care plans are in place and reviewed regularly by the manager and relatives. Care plans contain basic information about the individuals needs and how they should be met and are mainly around personal care tasks. The manager reported that care plans include peoples likes and dislikes and could include goals, although this information is in the local authority care plan and would be increasing the services paperwork. All people who use the service said that they are satisfied with the care and support they receive. Two questionnaires noted that relatives/friends are 10, Friday Road DS0000027223.V339122.R01.S.doc Version 5.2 Page 11 ‘always’ kept informed, that the home ‘always’ meets the needs of people who live at the home, that people ‘always’ get the care agreed and they expect and that the service ‘always’ and ‘usually’ meets peoples different needs. Relatives and friends comments included ‘the assurances I receive from the manager and staff put my mind at ease’ and ‘the home provides an excellent service, the one to one care is outstanding and the home is run with love and dedication’. Any health needs are noted in case files and staff provide support to individuals as required. Appropriate medication policies and procedures are in place. Medication is stored and labelled correctly and records were up to date and signed. 10, Friday Road DS0000027223.V339122.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People who use this service receive adequate quality in this outcome area. This judgement has been made using available evidence including a visit to this service. Set, planned activities are not provided. The food is of satisfactory quality, well presented and meets peoples dietary needs. EVIDENCE: People who use the service have access to a daily paper, the television, radio and a few board games. Staff were seen to sit with people and talk about the daily news, television programmes and peoples lives. A Catholic Communion is provided every week and a Church of England service is accessed by one person. People were generally in the lounge or their bedrooms during inspection visits. Visitors are welcome and are given an update of their relative or friend. Visitors tend to stay in the lounge but could see their relative in the dining room or garden, weather permitting. Two visitors noted that the home ‘always’ helps their relative or friend keep in touch. 10, Friday Road DS0000027223.V339122.R01.S.doc Version 5.2 Page 13 A varied menu is provided with a cooked meal at lunch time and a lighter snack in the late afternoon. Tea or coffee and biscuits are provided mid morning and afternoon and around bedtime. People made mixed comments about lunch, one person said ‘lunch was good’, one person said ‘I left the liver’ and another person said ‘I left the bacon’. 10, Friday Road DS0000027223.V339122.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use this service receive adequate quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The complaints procedure is displayed in the entrance hall in large print and is included in the brochure. Staff complete training in the protection of vulnerable adults. EVIDENCE: People who use the service and their relatives or friends were aware of how to make a complaint and had either not needed to make a complaint or raised an issue which had been addressed. No complaints have been received at the home or by the CSCI since the last inspection. Staff complete training in the protection of vulnerable adults and a suitable policy is in place. 10, Friday Road DS0000027223.V339122.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 24, 25 and 26 People who use this service receive adequate quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The home is comfortable and a redecoration schedule is in place. People who use services can personalise their rooms. The home is clean, warm and well lit. EVIDENCE: There is a lounge, dining room, toilet and shower room, and kitchen on the ground floor. A small paved garden is accessed through the dining room. Four single bedrooms, all have a toilet and wash hand basin and a bathroom with toilet are on the first floor. People’s comments about their rooms included ‘I’ve got all I need’, ‘I like my room’ and ‘I share with someone who can be quite noisy sometimes’. All areas were clean and free from odour. 10, Friday Road DS0000027223.V339122.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People who use this service receive adequate quality in this outcome area. This judgement has been made using available evidence including a visit to this service. People who use the services receive care that meets their needs. Staff levels are sufficient to meet peoples needs. Staff understand their role and what is expected of them. EVIDENCE: Friday Road is a small family run business which only employs a few staff to cover the cleaning, cooking and a few care hours each week. Two staff are on duty during the day and asleep but on call at the home at night. Staff were seen to be aware of peoples needs and how to meet them. Two questionnaires noted that staff ‘always’ and ‘usually’ have the skills and experience to meet peoples needs. Staff files were seen to include an application form, two written references and confirmation that a Criminal Records Bureau check was completed. Proof of identity and a recent photograph were not in staff files, these must be obtained to comply with Regulations. 10, Friday Road DS0000027223.V339122.R01.S.doc Version 5.2 Page 17 The owner has completed mandatory training in food hygiene, manual handling and fire safety through their other employment. Staff complete training in food hygiene and health and safety. Training is available for the owners and staff through the local authority, however this has not been accessed by the service. 10, Friday Road DS0000027223.V339122.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 People who use this service receive adequate quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The manager is qualified and has the necessary experience to run the home. The manager is aware of the need to keep up to date with practice and continuous development but finds it difficult to attend regular formal training. EVIDENCE: The manager has been at the home for a number of years and has previous experience working with older people. People who use the service are encouraged to be involved in the day to day running of the home but this is not always possible. The manager has sent out surveys to professionals involved with people living at the home and staff completed questionnaires with people in August 2006. 10, Friday Road DS0000027223.V339122.R01.S.doc Version 5.2 Page 19 People who use the service are generally supported by relatives to manage their finances. The manager looks after finances for one person and the placing authority are aware and keep a check on this. One member of staff has received supervision twice in 2007 and one member of staff has only received supervision once this year. This level of formal supervision is not in line with Regulations. Good health and safety checks and systems are in place. The weekly fire alarm test, the fire alarm service, emergency lighting service, electrical supply check and portable electrical appliance test are all up to date. 10, Friday Road DS0000027223.V339122.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 Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 2 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X 2 X X 2 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 3 10, Friday Road DS0000027223.V339122.R01.S.doc Version 5.2 Page 21 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. 2. Standard OP29 OP36 Regulation 19 & Sch 2 (1) 18 (2) Requirement Staff files must contain proof of the individuals identity and a recent photograph. All staff must receive formal one to one supervision six times a year. Timescale for action 06/09/07 06/09/07 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 OP7 Good Practice Recommendations It is recommended that care plans are further developed to make sure that good quality person centred information is recorded as required about areas such as life history, social and emotional needs and the individual’s likes and dislikes. Care notes should document activities that residents participate in and reflect the care and support given. It is recommended that any information supplied to residents be made available in large print and other accessible formats as appropriate. This is with reference to the Service Users Guide and individual contracts. 2. 3. OP12 OP2 10, Friday Road DS0000027223.V339122.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG 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 10, Friday Road DS0000027223.V339122.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. 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