Inspection on 09/05/06 for 10, Friday Road

This inspection was carried out on 9th May 2006.

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

The inspector 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 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 Jon Fry Unannounced Inspection 9th May 2006 10:45 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.V297242.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.V297242.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.V297242.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th November 2005 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. The home 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 of the home. Five service users are currently residing at the home. 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 home is provided to residents in a written brochure. The current range of fees are £389.00 to £400.00 per week. 10, Friday Road DS0000027223.V297242.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by a regulation inspector on the 9th May 2006. The inspection took place over four hours. The inspector spoke with four residents, the manager and one member of staff. A number of records were examined, as well as a tour of the communal areas of the home. Completed survey forms were received from five residents. Two individuals were supported by the home in completing these. What the service does well: What has improved since the last inspection? What they could do better: Care plans could be improved in order to be more individualised and reflect the social and emotional needs of residents. This information could be used to review the activities currently provided for residents. Three chairs provided for residents in the communal lounge require repair or replacement. The hot water temperatures of baths and showers need to be checked weekly to make sure they are not too hot for residents to use safely. 10, Friday Road DS0000027223.V297242.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. 10, Friday Road DS0000027223.V297242.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.V297242.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents are provided with basic information about the home to help them to make a decision about moving in. The needs of prospective residents are assessed prior to admission to make sure that the home will be able to meet these. EVIDENCE: There is a home brochure available that gives basic information about the home. This is adequate as the service is small in size and the registered owners work at the home. No new residents have been admitted to the home since the November 2005 inspection. Documentation seen for two residents included assessments from the placing care managers. A full review had been held for each of these residents within the last year. 10, Friday Road DS0000027223.V297242.R01.S.doc Version 5.2 Page 9 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, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans give basic information about the needs of residents including some of their likes and dislikes. The care plans could be better organised and developed further to include more ‘person centred’ information about each resident. There are satisfactory arrangements to make sure that medication is safely administered to residents. EVIDENCE: Care plans were looked at for two residents. These give basic information about the individual support required and are reviewed on a monthly basis. Care plans seen covered areas such as mobility, personal hygiene and confusion. The care documentation for each resident should be reviewed to make sure that only up to date information is kept within the current file. Information 10, Friday Road DS0000027223.V297242.R01.S.doc Version 5.2 Page 10 was sometimes difficult to find due to the amount of paperwork kept for each resident. The manager should also look at each care plan to see if they could be made more ‘person centred’. Areas such as life history, individual preferences and social and emotional needs could be better addressed. Information and goals included within the resident’s Local Authority care plan should also be reflected within the homes own care plan. Residents receive support to access local healthcare services such as the GP, dentist and the Community Mental Health Team (CMHT). Records for medication are well maintained. A pharmacy monitored dosage (MDS) system is used and the dossett boxes are stored within a locked storage space. 10, Friday Road DS0000027223.V297242.R01.S.doc Version 5.2 Page 11 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): 12, 13, 14 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Resident’s dietary needs are catered for. Residents participate in activities on an informal basis. Their social and emotional needs could be better reflected within the individual care plans. Residents confirmed that they retain contact with family and friends. EVIDENCE: Residents receive three meals a day with the main meal served at lunchtime. The lunch served at the time of inspection was sausage casserole, potatoes and cauliflower. One resident was seen to have an alternative lunch of tomato soup. Feedback from residents regarding the food provided included ‘the food is nice’, ‘good’ and ‘not bad’. The manager reported that activities were provided on an informal basis. The hairdresser visits once every three weeks and was at the home on the day of inspection. Representatives from the local Catholic Church visit every week to 10, Friday Road DS0000027223.V297242.R01.S.doc Version 5.2 Page 12 give communion to residents. Two Residents spoken to said that they don’t go out whilst another individual said that they ‘watch TV’. One resident said that they were ‘not interested in activities’. The social and emotional needs of residents could be better addressed within each individual care plan. The care notes made should additionally reflect any activities that residents take part in. Residents spoken to said that they were able to have visitors. 10, Friday Road DS0000027223.V297242.R01.S.doc Version 5.2 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 the following standard(s): 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. An adequate complaints procedure is in place at the home. This is made available to residents. Policies are in place for the Protection of Vulnerable Adults. New staff working at the home must receive training in abuse awareness. EVIDENCE: Systems are in place for recording any complaint made to the home. At the time of this visit the manager confirmed that no complaints had been received by the home since the November 2005 inspection. Residents spoken to said they had no complaints about the service at the time of this inspection. Policies are in place regarding the Protection of Vulnerable Adults. The manager reported that one new member of care staff needs to complete training regarding abuse awareness. The manager must ensure that the induction training undertaken by new care staff is to the national ‘Skills for Care’ standards that include how to recognise and respond to abuse and neglect. 10, Friday Road DS0000027223.V297242.R01.S.doc Version 5.2 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 the following standard(s): 19, 20, 21, 24, 25 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a homely environment that is generally maintained to a satisfactory standard. Minor improvements were seen to be required at the time of this inspection. The home is kept clean and tidy for residents. EVIDENCE: The residents spoken to said that they were satisfied with the accommodation provided. The home is small in size and provides a ‘homely’ domestic environment for the residents living there. Residents can access a lounge and dining room on the ground floor. A small garden is also available to the rear of the home. Residents spoken to said that they were satisfied with their bedroom accommodation. 10, Friday Road DS0000027223.V297242.R01.S.doc Version 5.2 Page 15 Communal areas and individual bedrooms are kept clean. A Local Authority Environmental Health Officer visited on the day of inspection. They stated that they were satisfied with the kitchen and Food Hygiene arrangements in place. Three chairs provided for residents in the communal lounge require repair or replacement. The ceiling in one resident’s bedroom needs re-decoration and consideration should be given to fitting alternative flooring around the toilet provided in this room. Old carpeting and bath chair equipment needs to be removed from the first floor hallway. The hot water provided in the first floor bathroom is too hot and needs to be restricted to a temperature of 44°C or below. 10, Friday Road DS0000027223.V297242.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels remain adequate to meet the care needs of residents currently accommodated. Induction training for new care staff must be reviewed. This will help to make sure that staff are competent to do their jobs. EVIDENCE: Two members of staff are on duty during the day and this level is adequate to meet the care needs of residents currently living at the home. Residents spoken to were generally positive about the staff at the home. Comments included ‘they are all kind to me’, ‘very nice’ and ‘alright’. One member of staff spoken to said that they felt good 1-1 care was provided at the home. The recruitment records for two members of staff were satisfactory. The manager reported that one new member of staff required abuse awareness training and another would be attending a Food Hygiene course. The training provided for new care staff must be updated to the new ‘Skills for Care’ common induction standards. These standards will be mandatory by September 2006. 10, Friday Road DS0000027223.V297242.R01.S.doc Version 5.2 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 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, 33, 35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from the small nature of the home and the individualised support that they receive. The home needs to regularly consult residents, their representatives and other professionals involved with the service. Their views must be used to inform the running of the home. Financial procedures require minor review to fully safeguard residents. Health and Safety procedures require review to fully ensure the safety of residents. 10, Friday Road DS0000027223.V297242.R01.S.doc Version 5.2 Page 18 EVIDENCE: The manager is a registered nurse and has managed the home for over eight years. The home is a small family run business with additional staff employed to assist the owners in the day-to-day running of the home. The registered persons need to develop the quality monitoring systems which will allow for an annual review of the service. This must take into account the views of residents, their relatives or representatives and other professionals. Survey forms are in use at the home and results from these must be collated to inform the review. The home keeps records for any money held on behalf of residents. It is strongly recommended that the home set a lower maximum limit for cash amounts held securely at the home. Reviews held for residents within the last year addressed individual financial arrangements. The records required by legislation are in place but would benefit from better organisation. Systems to ensure the Health and Safety of residents require further review. Hot water temperatures for baths and showers must be monitored each week with a record kept. All hot water outlets as used by residents must not exceed 44°C in temperature. Fire Extinguishers must be checked annually as these checks were overdue for this equipment at the time of inspection. 10, Friday Road DS0000027223.V297242.R01.S.doc Version 5.2 Page 19 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 3 3 X X 3 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 X X 2 10, Friday Road DS0000027223.V297242.R01.S.doc Version 5.2 Page 20 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. Standard OP18 Regulation 13 (6) Requirement The Registered Persons must ensure that all care staff have received abuse awareness training. The Registered Persons must ensure that: three chairs provided in the communal lounge are repaired or replaced, the ceiling in one first floor bedroom is re-decorated, old carpet and equipment in the first floor hallway is removed. 3. OP30 18 (1) The Registered Persons must ensure that all new staff receive induction training to national ‘Skills for Care’ specification. Full records must be maintained to evidence this. 4. OP33 24 The Registered Persons must 01/09/06 ensure that an annual development plan be put in place DS0000027223.V297242.R01.S.doc Version 5.2 Page 21 Timescale for action 01/09/06 2. OP19 23 (2) (b) (c) (d) 01/09/06 01/09/06 10, Friday Road for the home. This must reflect the views of residents, their representatives and other stakeholders in the service. 5. OP38 13 (4) 23 (4) (c) The Registered Persons must ensure that: weekly checks of bath and shower hot water temperatures are carried out with full records kept, all hot water outlets used by residents must not exceed 44°C, fire extinguisher equipment must be checked annually. 01/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations It is recommended that the systems for care planning be 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 plans should accurately reflect information contained within Local Authority documentation. 2. 3. 4. OP7 OP12 OP19 The Registered Persons should review the care plans and archive old records to ensure easy access to current information. Care notes should document any activities that residents participate in. It is recommended that alternative flooring be looked at DS0000027223.V297242.R01.S.doc Version 5.2 Page 22 10, Friday Road 5. OP35 for the areas around resident’s toilet facilities. It is recommended that a lower maximum limit be set for cash amounts held at the home on behalf of residents. 10, Friday Road DS0000027223.V297242.R01.S.doc Version 5.2 Page 23 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 10, Friday Road DS0000027223.V297242.R01.S.doc Version 5.2 Page 24 - 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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