Inspection on 06/05/05 for 10, Friday Road

This inspection was carried out on 6th May 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

10, Friday Road 03/07/07

10, Friday Road 09/05/06

10, Friday Road 07/11/05

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 Friday Road 10 Friday Road Mitcham Surrey CR4 3JQ Lead Inspector Emma Dove Unannounced 6 May 2005 10:00 am th 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 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. Friday Road G54-G04 S27223 Friday Road V226793 060505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Friday Road Address 10 Friday Road Mitcham Surrey CR4 3JQ 0208 648 7800 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) Mr Jose Martin Mrs Sylvia Rookmin Martin CRH Care Home 6 Category(ies) of MD (E) Mental Disorder over 65 (6) registration, with number OP Old age (6) of places Friday Road G54-G04 S27223 Friday Road V226793 060505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15/12/04 Brief Description of the Service: 10, Friday Road is a registered care home for six older people, which may include up to three older people who have additional mental health needs. Three service users are currently residing at the home. The home is owned and managed by two private individuals. The home is situated in a residential area on the borders of Mitcham and Tooting and is in keeping with neighbouring houses. Local shops and public transport systems are within a fifteen minute walk of the home. Accommodation is provided over two floors with a lounge, dining room, kitchen, double bedroom, laundry area and shower room with a toilet available on the ground floor. The first floor is accessed via a narrow staircase with stair rail and provides four single bedrooms with a wash hand basin and toilet which is screened with a curtain. The manager uses one single bedroom for on call purposes. Residents have access to a small paved garden to the rear of the home. The home is staffed twenty-four hours a day. Three meals a day are provided with drinks and snacks available between meals. Friday Road G54-G04 S27223 Friday Road V226793 060505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over the course of one day by one inspector. The inspection consisted of examination of records, inspection of communal areas of the home, talking to residents, the manager and staff. The inspector spoke with three residents and one member of staff. What the service does well: What has improved since the last inspection? What they could do better: The care planning process requires updating to include residents involvement in developing the care plan. Daily recording must be factual. Residents should be involved in the annual review of the care they receive. Friday Road G54-G04 S27223 Friday Road V226793 060505 Stage 4.doc Version 1.30 Page 6 Staff should receive training in the care of people with mental health issues and residents finances must be discussed with the placing authority with money securely stored at the home. 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. Friday Road G54-G04 S27223 Friday Road V226793 060505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Friday Road G54-G04 S27223 Friday Road V226793 060505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 4 and 5. Information provided by the home is brief but assists prospective residents with their decision to move into the home. EVIDENCE: A sheet containing the homes aims and objectives, dated September 2002 and a copy of the booklet given to residents on admission to the home were available for inspection. The booklet has been updated since the last inspection. The booklet contains information regarding the homes registration, facilities available at the home, services which require an additional fee, religious observance, staffing, visitors to the home and complaints. This gives potential residents information they require to assist with their decision to move into the home. Examination of three individual case files identified that they contained a copy of the contract of residence with the home. The contract of residence details the trial period on admission, fees charged, personal effects, staffing, outings, assessments, medication, termination of the contract, registration, complaints, confidentiality and insurance. Friday Road G54-G04 S27223 Friday Road V226793 060505 Stage 4.doc Version 1.30 Page 9 The last admission to the home was in 2003, a full social work assessment was not received prior to admission although very detailed information was received from previous placements and medical professionals. The staff team comprises of individuals from multi cultural backgrounds. A Requirement was made at the last inspection of the home regarding staff completing training in the care of people with dementia. The manager reported that staff could access a training session on working with people with mental health issues in June 2005. This would be a more appropriate training session for staff to ensure that current residents needs are met. Friday Road G54-G04 S27223 Friday Road V226793 060505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 and 9. Residents health and welfare is promoted by the recording systems in place at the home. Residents are not offered regular opportunities to comment upon the services provided at the home. Residents are protected by the medication policies and medication administration practices within the home. EVIDENCE: Examination of three individual case files identified that they contained a care plan. The manager has reviewed care plans monthly. Evidence is not available confirming residents involvement in developing and reviewing care plans. Care plans are basic, detailed information regarding two residents personal care needs were in their bedrooms, for staff. One case file contained a copy of review meeting minutes dated February 2004. The manager reported a further review had taken place although evidence was not available to confirm this. One case file contained a copy of a review in 2003. Regular reviews of the care and services provided at the home should take place to enable residents and their representatives the opportunity to comment on services provided. Residents health is protected by them being registered with a GP, a chiropodist and optician visit the home when required. The community nurse is available Friday Road G54-G04 S27223 Friday Road V226793 060505 Stage 4.doc Version 1.30 Page 11 to assess residents continence needs. Residents are weighed monthly with any concerns reported to the GP. Medication is securely stored, Medication Administration Record Sheets were signed and up to date. One medication for one resident was found to be in the blister pack. The manager reported that the resident had been given a liquid alternative and this must be requested through the GP. The pharmacist visited the home in February 2005 with no issues raised. Friday Road G54-G04 S27223 Friday Road V226793 060505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 and 13 Residents can continue to pursue hobbies on admission to the home, however planned activities are not provided at the home. Residents are encouraged to maintain contact with family and friends. Residents can continue their religious observance during their stay at the home. EVIDENCE: Three residents reported that they watch television, read newspapers, receive visitors, speak with staff, attend communion service at the home and listen to the radio. Parties for residents and relatives are held two or three times a year. Two residents reported that they choose when they get up in the morning. Birthdays and other occasions are celebrated. Visitors are welcome at the home and can be seen in the lounge, dining room or individuals bedrooms. Representatives from the local Catholic Church visit every week to give communion to residents. One resident confirmed that this is important to their life. Friday Road G54-G04 S27223 Friday Road V226793 060505 Stage 4.doc Version 1.30 Page 13 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 17 & 18. A complaints procedure is in place at the home, which is available to residents. Systems are in place to record complaints received at the home which promotes residents welfare. Residents financial arrangements are not protected by the manager being involved in their finances with no input from placing social workers. EVIDENCE: The complaints procedure is included in the booklet given to residents on admission to the home. Two residents confirmed that they would raise concerns with the manager. Records would be made of complaints received at the home. No complaints have been received since the manager has been at the home. The CSCI received one complaint regarding additional charges made at the home. This complaint was upheld. Two residents said that they can use the postal voting system or visit local polling station to take part in the electoral process. Policies are in place regarding the protection of vulnerable adults. The manager reported that two staff are due to complete training in the protection of vulnerable adults in June 2005. Friday Road G54-G04 S27223 Friday Road V226793 060505 Stage 4.doc Version 1.30 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 & 22. The home is in keeping with neighbouring houses. It has not been specifically adapted for people with mobility issues, which limits whom the service is available to. EVIDENCE: The home is a small domestic environment which has been adapted over the years for its current purpose. Residents access the first floor via a narrow staircase which has a handrail. Residents who are not able to walk well are not able to use the bathroom upstairs. A small shower room with toilet is available on the ground floor. The lounge is furnished with comfortable chairs, a low table, a sofa bed which is used by staff for night on call purposes and a television and video. The dining room has a large table and sufficient chairs for residents and staff. A schedule of redecoration is in place at the home with a number of areas having been painted since the last inspection. The Environmental Health Officer visited in February 2005 and noted issues with cockroaches and evidence of mice having been in the kitchen. The Friday Road G54-G04 S27223 Friday Road V226793 060505 Stage 4.doc Version 1.30 Page 15 manager responded appropriately by calling pest control, who visited twice and carried out treatments. A repair was made also made to the external wall in the kitchen. The CSCI were not informed of these issues. Requirements were made at the last inspection of the home regarding the recommendations from the Occupational Therapists report being completed. A new stair rail and a rail to the front door have been fitted at the home to meet this Requirement. Friday Road G54-G04 S27223 Friday Road V226793 060505 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 & 30. Staff numbers are adequate to meet residents needs. EVIDENCE: The home is a small family run business with five staff employed on a part time basis to assist the owners in the day-to-day running of the home. Two members of staff are on duty at the home during the day with two asleep but on call at the home at night. The manager is at the home six days a week. Residents made positive comments regarding staff including ‘they’re nice and they help me as requested’. The cook has completed training in food hygiene, this meets a Requirement made at the last inspection of the home. The manager reported that they access training through the National Association of Care Homes, with two staff due to do training in the protection of vulnerable adults. Friday Road G54-G04 S27223 Friday Road V226793 060505 Stage 4.doc Version 1.30 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 Residents financial interests are compromised by the manager holding individuals finances and not discussing purchases and expenses with the placing social workers. EVIDENCE: Two residents manage their own finances or have a relative who act in their interest. The manager holds finances for one resident. Residents money is not securely stored at the home which puts residents in a vulnerable situation. Records are maintained of expenditure and income. The record was up to date and the balance was slightly high where ‘change’ was not available. This was clearly recorded. Friday Road G54-G04 S27223 Friday Road V226793 060505 Stage 4.doc Version 1.30 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 x COMPLAINTS AND PROTECTION 2 x x 3 x x x x STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 2 x x x x 2 x x x Friday Road G54-G04 S27223 Friday Road V226793 060505 Stage 4.doc Version 1.30 Page 19 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. Standard 4 Regulation 19 (5) b Requirement The registered person must ensure that staff receive training in the care of people with mental health problems. The registered person must ensure that residents involvement in the care planning process is recorded and that daily recording is factual. The registered person must ensure that medication is administered to the resident it is prescribed for. The registered person must ensure that the CSCI is informed of issues raised by Environmental Health Officers which affect the health and welfare of residents. The registered person must ensure that residents finances are securely stored at the home and that the placing authority is involved in financial arrangements. Timescale for action 30/06/05 2. 7 15 (1) & (2) 30/06/05 3. 9 13 (2) 30/06/05 4. 19 16 (2) j & 13 (3) & (4) 30/06/05 5. 35 16 (2) l & 17 (2) & Schedule 4 (9) 30/06/05 Friday Road G54-G04 S27223 Friday Road V226793 060505 Stage 4.doc Version 1.30 Page 20 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 Good Practice Recommendations Friday Road G54-G04 S27223 Friday Road V226793 060505 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection Ground Floor - CSCI 41-47 Hartfield Road Wimbledon 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. 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