Inspection on 16/02/06 for 179, Green Lane

This inspection was carried out on 16th February 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

179, Green Lane 30/07/07

179, Green Lane 24/11/06

179, Green Lane 14/06/05

179, Green Lane 31/08/04

179, Green Lane 27/04/04

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 179, Green Lane Morden Surrey SM4 6SG Lead Inspector Louise Phillips Unannounced Inspection 16th February 2006 12:40p 179, Green Lane DS0000019094.V283942.R01.S.doc Version 5.1 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 179, Green Lane DS0000019094.V283942.R01.S.doc Version 5.1 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 Adults 18-65. 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. 179, Green Lane DS0000019094.V283942.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 179, Green Lane Address Morden Surrey SM4 6SG 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) 020 8648 1307 www.caremanagementgroup.com Care Management Group Limited Miss Iye Fornah Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5) of places 179, Green Lane DS0000019094.V283942.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Female adults with Learning Disabilities Psychological needs and behavioural problems Date of last inspection 14th and 24th June 2005 Brief Description of the Service: 179 Green Lane is a care home with nursing, providing care to five females who have mental health needs. The home is situated close to public transport links and a small number of local shops. Accommodation is provided over two floors, with en-suite rooms for each resident. There is also a well-maintained garden to the rear of the property. 179, Green Lane DS0000019094.V283942.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over one day with time spent talking to staff, residents and viewing paperwork. A tour of the premises was carried out and care records were inspected. A number of standards were not assessed on this occasion due to the manager not being present and the inspector was unable to access information relevant to particular standards. 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. 179, Green Lane DS0000019094.V283942.R01.S.doc Version 5.1 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 179, Green Lane DS0000019094.V283942.R01.S.doc Version 5.1 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 The home has a clear assessment process that looks at all the needs of the individual. This enables residents to be confident that 179 Green Lane is the right home for them. EVIDENCE: The documentation details that a thorough assessment of each residents needs is carried out prior to their moving to the home, involving input from the resident and relevant healthcare professionals. During the assessment period the staff work with the new resident to find out relevant details that are important to their having a good quality of life at the home. This includes finding out what the resident likes to eat, when they like to eat, what times they like to get up in the morning, go to bed at night and if they pursue any religious activities, etc. New residents are given a good induction to the home, being introduced to the other residents and staff team and being shown what to do if the fire alarm should go off. 179, Green Lane DS0000019094.V283942.R01.S.doc Version 5.1 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 There is a clear and consistent care planning system in place to provide staff with the information they need to meet residents’ needs. The risk assessments need to improve to ensure that they are updated after any incident involving the resident. EVIDENCE: During the inspection two residents files were examined and these are in a good format. The care plans for each resident have been drawn directly from the assessment records with all needs identified and planned for. The format of the care plans is simple, easy to understand, individualised and easy to recognise each persons’ current needs. The care plans are drawn from a ‘list of priorities’ of the assessment information and developed into care plans that cover a variety of needs such as community participation, personal care, employment, education, recreation, relationship and sexual needs. The care plans are reviewed monthly with each resident. The care plans are typed, yet the home does not have a computer. It was recommended at the previous inspection that the home have a computer on site to ensure that information is given to residents in a timely manner, so that 179, Green Lane DS0000019094.V283942.R01.S.doc Version 5.1 Page 9 needs are met and any risk to residents is minimised. The staff stated that the care plans are written by staff and then sent to the head office to be typed and then returned to the home. This creates a time delay barrier if care plans are changed to meet the changing needs of residents, or in response to an unforeseen situation. It is required that this practice be reviewed and the care plans are in a written format, or a computer be provided at the home for the use of staff. Each file contained an assessment of any areas where there was considered to be a risk to the resident or others along with how these risks were to be dealt with and reduced as far as possible. These include areas such as allegations against staff, neglecting personal care or verbal abuse. However several incidents had occurred with one resident since the last inspection, where they had become aggressive towards staff and throwing items, yet none of these were written in the risk assessment and it was not clear how these behaviours are managed by the home. Also, an incident report for one resident detailed that they had made racist remarks towards staff, yet this was also not included in a risk management plan. It is not clear how staff are supported when this occurs. The staff spoken to about this stated that “…you just get used to it…”. A requirement has been made to ensure that verbal aggression by residents is appropriately managed and that appropriate support is provided to staff who encounter this. 179, Green Lane DS0000019094.V283942.R01.S.doc Version 5.1 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed on this occasion. EVIDENCE: 179, Green Lane DS0000019094.V283942.R01.S.doc Version 5.1 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 and 21 The home has a good medication system that ensures residents receive their medicine safely. EVIDENCE: The systems in place for the administration of medication are good, where staff can clearly identify each medication before being given to the resident. There is also an up-to-date medication policy that outlines safe procedures for staff to follow when giving out the medicines. The medication files include details of staff who are authorised to administer medication, guidelines for administration, homely remedies consent form signed by the General Practitioner and a photo of each resident. The medicine charts were all signed appropriately and medication stored securely. Each resident file contains a form regarding their personal wishes regarding the event of their death at the home, with records kept if a resident has declined to discuss these issues. 179, Green Lane DS0000019094.V283942.R01.S.doc Version 5.1 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 Aggression by residents is not always appropriately managed by the home. EVIDENCE: As stated earlier in the report, some incidents concerning residents are not recorded in a risk management plan and it not clear how these behaviours are managed by the home. A requirement has been made to ensure that verbal aggression by residents is appropriately managed and that appropriate support is provided for those who encounter this. 179, Green Lane DS0000019094.V283942.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 Décor both inside and outside the home needs to improve for the comfort of the residents. EVIDENCE: Since the last inspection the flooring to one residents en-suite bathroom has been replaced, making the area more comfortable. However, it was observed that the bathroom floor in room 4 needs replacing as there are gaps around the base of where the sink has been changed. The bath mats in this room also need replacing, as the current ones are stained. Further to this, the bathroom in bedroom 3 needs repainting. In summarising, there are noticeable differences in the décor to each resident’s bedroom/ bathroom areas, with some very nicely decorated and others in need of decoration and repair (as identified above), and requirements have been made to address these shortfalls. In addition, an area still outstanding from the last inspection is the external walls of the home which is shabby-looking, with old paint peeling off and not at all homely. 179, Green Lane DS0000019094.V283942.R01.S.doc Version 5.1 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed on this occasion. EVIDENCE: 179, Green Lane DS0000019094.V283942.R01.S.doc Version 5.1 Page 15 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39 and 41 The home does not demonstrate that the views of the residents, staff or relevant professionals are sought and used to develop the service. EVIDENCE: On the day of inspection the manager was not at the service. Staff at the home stated that they were not aware of any quality assurance systems in place to seek feedback from residents, relatives or relevant professionals on the service provided. The records at the home also indicate that the last residents meeting was in May 2005, and the last staff meeting in June 2005. There was no evidence to demonstrate that feedback is sought from residents, staff, etc. to improve the quality of the service and a requirement has been made to ensure that a quality assurance system is implemented at the home. Record-keeping in the daily care notes is of a good standard, with clear information as to what the resident has done throughout the day, observations of their mood and their interactions with the staff and residents. 179, Green Lane DS0000019094.V283942.R01.S.doc Version 5.1 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 3 3 X X 1 X 3 X X 179, Green Lane DS0000019094.V283942.R01.S.doc Version 5.1 Page 17 Are there any outstanding requirements from the last inspection? YES 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 YA6 Regulation 15(2)(a) & (b) Requirement The Registered Persons must ensure that the care plans are in written format or provide a computer at the home to enable staff to transfer these to typed format. The Registered Persons must ensure that: - risk assessments are reviewed regularly and updated following any incident involving the resident. - verbal aggression by residents is appropriately managed and support provided to residents/ staff encountering this. The Registered Persons must ensure that: - the bathroom floor and bathmats in room 4 is replaced - the bathroom in bedroom 3 is repainted The Registered Persons must ensure that the exterior of the home is painted (previous timescale not met) The Registered Persons must ensure that a system for reviewing the quality of the service is implemented, along DS0000019094.V283942.R01.S.doc Timescale for action 31/08/06 2. YA9YA23 12(1) & 13(6) 30/04/06 3. YA24 23(2)(b) 31/08/06 4. YA24 23(2)(b) 30/04/06 5. YA39 24 30/04/06 179, Green Lane Version 5.1 Page 18 with regular resident and staff meetings. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 179, Green Lane DS0000019094.V283942.R01.S.doc Version 5.1 Page 19 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 179, Green Lane DS0000019094.V283942.R01.S.doc Version 5.1 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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