Inspection on 07/11/05 for 10, Friday Road

This inspection was carried out on 7th November 2005.

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 03/07/07

10, Friday Road 09/05/06

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 Friday Road, 10 10 Friday Road Mitcham Surrey CR4 3JQ Lead Inspector Emma Dove Unannounced Inspection 7th November 2005 2:00 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 Friday Road, 10 DS0000027223.V266122.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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, 10 DS0000027223.V266122.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Friday Road, 10 Address 10 Friday Road 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) Friday Road, 10 DS0000027223.V266122.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 06/05/05 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. Five service users are currently residing at the home. The home is owned and managed by two private individuals. 10, Friday Road 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, 10 DS0000027223.V266122.R01.S.doc Version 5.0 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 four hours one afternoon by one regulatory inspector. The inspection consisted of examination of records, inspection of communal areas of the home, five residents bedrooms, talking to residents, visitors, the registered manager and staff. The inspector had the opportunity to speak with five residents, one visitor and one member of staff. Residents made positive comments regarding the home and the service they receive. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Friday Road, 10 DS0000027223.V266122.R01.S.doc Version 5.0 Page 6 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 Friday Road, 10 DS0000027223.V266122.R01.S.doc Version 5.0 Page 7 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 the following standard(s): 1&4 Prospective residents are provided with a leaflet regarding the home which includes brief information to assist them in deciding to move into the home. EVIDENCE: The manager reported that no changes have been made to the information given to prospective residents since the last inspection. The manager has completed a one day training session on Mental Health in later life since the last inspection and will be able to brief staff with relevant information. This should offer some residents more appropriate care. Friday Road, 10 DS0000027223.V266122.R01.S.doc Version 5.0 Page 8 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 the following standard(s): 7, 8 & 10 Residents health and personal needs are included in care plans. Residents are treated with respect. EVIDENCE: Two case files examined included a social work report, a brief needs assessment and a care plan. Care plans give information on the basic needs of residents including some of their likes and dislikes. Care plans do not evidence the involvement of residents and relatives. Information on how individuals needs will be met is not clear, due to the home being a small family run business with a few members of staff employed. The manager said that the information for meeting individuals needs is sufficient. One case file did not include a risk assessment for smoking, this must be completed with clear written details to ensure the individuals health and safety is maintained. Appropriate records are maintained of individuals weight. Residents have access to a telephone in the lounge. Residents wear their own clothing. Staff call residents by their first names, residents were satisfied with this arrangement. The manager reported that new members of staff receive information on how to treat residents with respect during their induction to the home. Friday Road, 10 DS0000027223.V266122.R01.S.doc Version 5.0 Page 9 One bedroom is double and two residents currently share, screening is provided. One resident confirmed that they are happy to be sharing a bedroom. Friday Road, 10 DS0000027223.V266122.R01.S.doc Version 5.0 Page 10 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 the following standard(s): 14 & 15 Residents maintain choices in daily life at the home regarding clothing, activities and meals. Residents dietary needs are catered for. EVIDENCE: Residents confirmed that they choose their clothing and activities. Residents receive three meals a day with the main meal served at lunchtime. Mealtimes are not hurried and residents made positive comments regarding the quality and quantity of food they receive at the home. One resident said ‘the food is generally good’ and another person said ‘tea looks good’. Friday Road, 10 DS0000027223.V266122.R01.S.doc Version 5.0 Page 11 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 the following standard(s): None of the above standards were addressed during the course of this inspection. EVIDENCE: Friday Road, 10 DS0000027223.V266122.R01.S.doc Version 5.0 Page 12 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 the following standard(s): 20, 21, 22, 23, 24, 25 & 26 The home provides a safe environment for residents. There are sufficient toilets and bathrooms to meet residents needs. Residents have access to the aids and adaptations they require. EVIDENCE: Residents have access to a lounge and dining room on the ground floor. A small garden is available to residents at the rear of the home. The manager reported that smoking is not permitted in the lounge. One resident was satisfied with the arrangements for smoking and one resident was pleased that there is no smoking in the lounge. A shower room with toilet is available on the ground floor and a bathroom with toilet is on the first floor. Three bedrooms have a toilet which is surrounded by a curtain and a wash hand basin. The bathroom is a small room of domestic proportions, it is fitted with a small bath chair which is old and in need of updating and an old bathroom suite which is looking ‘tired’. The manager is aware that the bathroom needs attention, however reported that it is a small space and will be difficult to fit with larger modern equipment. Friday Road, 10 DS0000027223.V266122.R01.S.doc Version 5.0 Page 13 An occupational therapist has assessed the home and recommendations made have been actioned. The home has been developed and altered over the years and is not specifically designed for people with mobility issues. Residents with limited mobility are not able to access the bathroom upstairs and have to use the shower. The current residents did not raise this as an issue. Residents can bring personal possessions to the home, however not all bedrooms have been personalised. The home has central heating, residents did not raise any issues regarding heating, lighting or water provided at the home. All areas of the home were clean and free from offensive odour. The laundry area is accessed through the dining room and a small corner of the kitchen. The laundry area is carpeted, this has not been raised as an issue by the Environmental Health officer. Friday Road, 10 DS0000027223.V266122.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28 & 29 Staffing levels were observed to be appropriate during the course of the inspection. Appropriate recruitment policies are in place, however some of the practices do not ensure residents are protected from harm. EVIDENCE: Two members of staff are on duty during the day with two staff asleep but on call at the home at night. These staffing levels were observed to be sufficient during the course of the inspection. Residents made positive comments regarding staff at the home, two residents said that they are pleased when the owner is at the home. The home is a small family run business with a few members of staff employed to support the owner, manager and their family in caring for residents. The manager reported that one new member of staff has been employed since the last inspection. Staff files contain two references, one reference was addressed ‘to whom it may concern’ and one reference was ‘dear sir/madam’. References should be addressed to the manager and be in relation to the position applied for. One file contained a copy of the POVA first check and clear guidelines must be in place for this member of staff to be supervised at all times until the full CRB check is received. The manager reported that staff have attended training in manual handling since the last inspection. Friday Road, 10 DS0000027223.V266122.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 36, 37 & 38 Residents benefit from the small nature of the home and the individualised support that they receive. Residents health and safety is protected by polices, procedures and practices at the home. EVIDENCE: The owner and manager have previous experience working with older and vulnerable people and have been at the home for over seven years. The manager demonstrated knowledge and understanding of conditions relating to old age. The manager reported that they have a development plan for the home which includes redecoration and have considered addressing the bathroom in this plan. The manager reported that they have not completed any quality assessments since the last inspection and will be completing this with new relatives. Residents and relatives were able to speak in private with the inspector. Appropriate insurance cover is in place. A business plan was in place at the home for the last year but this had not been completed for this year. Friday Road, 10 DS0000027223.V266122.R01.S.doc Version 5.0 Page 16 Staff receive supervision from the manager, however records indicated that one new member of staff had not received more frequent supervision on commencing employment at the home. The records required by legislation are in place, however they are not easily accessible and should be organised to ensure they are accessible. Residents and staffs health and safety are protected by policies and practices at the home. All health and safety checks were up to date, again the records could be organised to make them more easily accessible, with old records archived. Friday Road, 10 DS0000027223.V266122.R01.S.doc Version 5.0 Page 17 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 3 X X 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X 3 2 3 3 3 3 3 STAFFING Standard No Score 27 X 28 3 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 X 2 2 3 Friday Road, 10 DS0000027223.V266122.R01.S.doc Version 5.0 Page 18 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 OP7 Regulation 15 (1) & (2) 19 (1) b Requirement The registered person must ensure that residents and relatives involvement in the care planning process is recorded. The registered person must ensure that the recruitment practices include a CRB check and for clear supervision guidelines to be in place while awaiting CRB checks for new staff. The registered person must ensure that clear records are maintained of the induction process for new staff. Timescale for action 30/12/05 2. OP29 30/12/05 3. OP36 18 (1) c 30/12/05 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 2 Refer to Standard 21 37 Good Practice Recommendations The registered person should give consideration to refurbishing the bathroom. The registered person should review the record keeping DS0000027223.V266122.R01.S.doc Version 5.0 Page 19 Friday Road, 10 and archive old records to ensure easy access to records. Friday Road, 10 DS0000027223.V266122.R01.S.doc Version 5.0 Page 20 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 Friday Road, 10 DS0000027223.V266122.R01.S.doc Version 5.0 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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