Inspection on 29/11/06 for 2 Mundania Road

This inspection was carried out on 29th November 2006.

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 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

2 Mundania Road 25/11/08

2 Mundania Road 20/10/05

2 Mundania Road 14/07/05

2 Mundania Road 01/02/05

2 Mundania Road 02/11/04

2 Mundania Road 13/03/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 2 Mundania Road London SE22 0NG Lead Inspector Pam Cohen Unannounced Inspection 29 November 2006 10:00 2 Mundania Road DS0000007091.V321721.R01.S.doc Version 5.2 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 2 Mundania Road DS0000007091.V321721.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 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. 2 Mundania Road DS0000007091.V321721.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 2 Mundania Road Address London SE22 0NG 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 693 1983 0208 693 9276 Mundania@saffronland.co.uk Saffronland Homes Care Home 6 Category(ies) of Learning disability (6), Physical disability (0) registration, with number of places 2 Mundania Road DS0000007091.V321721.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20 October 2005 Brief Description of the Service: Mundania Road is registered to provide accommodation and care to 6 service users with learning disabilities. At the time of this inspection there were 4 male service users living at the home. The house is a large Victorian style 3 storeydetached building in a side street close to many local shops, community services and transport links. There is a large communal dining area and lounge with a communal kitchen on the lower ground floor. There is a garden with patio at the back of the house. There is no lift and the house is not wheelchair accessible. 2 Mundania Road DS0000007091.V321721.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on the afternoon of 29th November. The manager facilitated the inspection with discussion and relevant documentation. The inspector also toured the home and spoke to the member of staff on duty. A service user showed the inspector his room and although communication was limited, he spoke about the home. The manager said that weekly fees were between £1,800 and £2,100 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. The summary of this inspection report can be made available in other formats on request. 2 Mundania Road DS0000007091.V321721.R01.S.doc Version 5.2 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 2 Mundania Road DS0000007091.V321721.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,4,5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users have most information they need about the home, although it should be produced in a more accessible format. There is a good process for ensuring that the home only takes service users whose needs they can meet, and who have actively chosen to live in the home. EVIDENCE: The home has a statement of purpose and service user guide. This needs to be updated and should include staff qualifications as well as a sample of service users’ views on the home. It should also be produced in a format accessible to this service user group. The manager is at the moment in the process of assessing whether a prospective service user could be appropriately supported at Mundania Road. This process involves ensuring the home has an up-to-date community care assessment, overnight visits and taking part in some social activities. A needs and risk assessment will then be carried out which will lead, as with the service users already in the home, to an individual plan. Service users’ files have individual written statements of terms and conditions. 2 Mundania Road DS0000007091.V321721.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can know that their support needs are detailed in individual plans, although goals are not. The home endeavours to help service users make as many choices as possible and good risk assessments support as independent a life style as possible. EVIDENCE: All service users have individual plans which include details of their support needs; these plans are reviewed 6 monthly. They include any restriction of choice, good risk assessments where needed, and detailed information on how to deal with any challenging behaviour. There was however, no evidence on the file seen that the support plan had been set up or reviewed with the service user and family. The plans also need measurable aims and targets to achieve desired goals. The individual plans are not yet available in a format accessible to the service user. 2 Mundania Road DS0000007091.V321721.R01.S.doc Version 5.2 Page 9 Service users are helped to make decisions about their lives through meetings with their key worker and through weekly planning meetings where for instance, the following week’s menu is decided. Staff work with different service users in different ways to enable them to make as many choices as possible, and have recently been working with the local multi-disciplinary support team in order to find better strategies for this. The inspector saw instances that showed that service users are well able to make clear what they want. 2 Mundania Road DS0000007091.V321721.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are well supported to have as varied and rewarding a lifestyle as possible. EVIDENCE: Service users have the opportunity to take part in a wide range of activities. At the time of inspection service users were out at a club and gardening and there are further varied activities during the week, together with social activities in the evenings. An activities room has been added to the home and contains a keyboard and a computer as well as games. It is hoped that this room will also double as a sensory room. The service user at home during the inspection was having his second session of music therapy. Staff have also been working with the multi-disciplinary team to learn strategies to try and encourage this service user to undertake other activities. There is good support from staff to facilitate on-going relationships. Two service users spend weekends at home with their family, a third is helped to 2 Mundania Road DS0000007091.V321721.R01.S.doc Version 5.2 Page 11 entertain his relative at Mundania road for Sunday lunch. Birthdays are celebrated at the home with families coming in. Each service user’s daily activities includes work around the house which is made possible by one-to-one staff working. Service users are able to shop, prepare food as much as they are able and do other things around the home. The menu seems healthy and nutritious and the service user who spoke to the inspector said he enjoyed food at the home. There is an issue with service users overeating if food is left out, so most food is locked away but with some snacks and fresh fruit left out. The need for this is recorded in service users’ files. 2 Mundania Road DS0000007091.V321721.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users health care needs, including medication administration, are looked after well. EVIDENCE: Given the limited communication abilities of the service users it is difficult to properly judge at an inspection, if service users are being offered personal care in the way they prefer. However one service user was clear that staff are kind to him and communication between another service user and staff was seen to be warm, with the service user making his wishes clear. Evidence from files showed that the home continues to work well with appropriate professionals to ensure that service users’ physical and emotional needs are met. Medication administration procedures were checked and seen to be in order, with good training for staff in this area. 2 Mundania Road DS0000007091.V321721.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Appropriate policies and procedures mean that complaints are acted upon, and as far as possible service users are protected from abuse. EVIDENCE: The home has a complaints policy and keeps a record of complaints made and the outcome of investigations. The commission has received complaints during the year from the mother of a service user who has now left the service. The latest of these was discussed with the manager during the inspection. The home has a vulnerable adults’ policy and since the last inspection, has dealt promptly and properly with two allegations of abuse. Training on issues of working with vulnerable adults is part of induction training as well as forming part of the ongoing training programme. The member of staff who spoke to the inspector said that she had attended training in the past year. 2 Mundania Road DS0000007091.V321721.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is comfortable homely and safe although some routine maintenance is needed and service users need some extra items of furnishing in their rooms. EVIDENCE: The home is comfortable and homely and all actions need to make it safe had been taken. The communal areas are well sized and nicely decorated. However they were spoilt by bad staining on ceilings which had happened some time before and which need to be remedied. A service user showed the inspector his bedroom. It is a good size and well personalised and he was happy with it. However there needs to be two comfortable chairs in service user bedrooms as well as a bedside light. There are ample toilets and bathrooms in the home. On the day of inspection the home was clean throughout. However there is not a proper system for the disposal of clinical waste and this must be put into place. 2 Mundania Road DS0000007091.V321721.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,35,36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Well trained and supported staff are deployed in sufficient numbers to support service users. EVIDENCE: Since the last inspection the home has filled the deputy manager’s post and filled care staff vacancies which means there is better consistency of care. All service users have 1-1 care. A majority of staff have an NVQ qualification and there is also a good programme of training based on the needs of service users and the training needs of staff. This includes mandatory areas such as health and safety and dealing with vulnerable adults, as well as specialist training in the area of learning disabilities and also training on individual service user’s needs. There is a programme of appraisal and supervision of staff and a member of staff who spoke to the inspector said that the manager was supportive and would always help and that there was an open atmosphere in the home. 2 Mundania Road DS0000007091.V321721.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a well run home and are protected by good Health and Safety procedures. However they cannot be sure that their views and those of their families and other stakeholders are taken into account in the planning and running of the service. EVIDENCE: The manager has completed his NVQ 4 and is working for his registered manager’s award. Evidence from the inspection showed that he is running the home well. The home works with families where they are able, to find out their views of the service, but still needs to put into place a full system for quality assurance and annual development. 2 Mundania Road DS0000007091.V321721.R01.S.doc Version 5.2 Page 17 Checks of the building and of documentation showed that health and safety issues are well dealt with. 2 Mundania Road DS0000007091.V321721.R01.S.doc Version 5.2 Page 18 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 2 2 3 3 x 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 2 27 3 28 3 29 x 30 2 STAFFING Standard No Score 31 x 32 3 33 3 34 x 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 2 x x 3 x 2 Mundania Road DS0000007091.V321721.R01.S.doc Version 5.2 Page 19 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 YA1 Regulation 5(1) Timescale for action The registered person must 31/03/07 ensure that all necessary information is included in an up-to-date service user guide. The registered person must 31/03/07 ensure that individual support plans are accessible for the service user, are drawn up and reviewed with the service user and their relatives, and that they include how new goals can be met. 28/02/07 Requirement 2. YA6 15(1) 3. YA24 23(2)(b)(d) 4. YA26 5. YA30 6. YA39 The registered person must ensure that routine maintenance is carried out to keep the fabric of the building in good condition. 16(2)(c) The registered person must ensure that service users have in their bedroom two comfortable chairs and a bedside light. 16(2)(k) The registered person must ensure that there is a proper system for disposal of clinical waste. 24(1)(2)&(3) The registered persons must ensure that a comprehensive quality assurance system is in DS0000007091.V321721.R01.S.doc 28/02/07 31/01/07 30/06/07 2 Mundania Road Version 5.2 Page 20 7. YA39 operation in the home that is based on the views of service users and other stakeholders. Target date of 31/12/05 not met. 24(1)(2)&(3) The registered persons must 30/06/07 ensure that an annual development plan is drawn up for the home that is based on the views of service users and other stakeholders and which is published and made available to service users, stakeholders and the Commission. Target date of 31/12/05 not met. 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 YA1 YA39 Good Practice Recommendations The registered persons should ensure that the Statement of Purpose and Service user guide are produced in a format accessible to the service user group. The registered persons should consider using an externally recognised, professional quality assurance tool within the home. 2 Mundania Road DS0000007091.V321721.R01.S.doc Version 5.2 Page 21 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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