Inspection on 25/11/05 for 89 Grosvenor Avenue

This inspection was carried out on 25th 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 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

89 Grosvenor Avenue 22/07/08

89 Grosvenor Avenue 04/12/07

89 Grosvenor Avenue 30/05/06

89 Grosvenor Avenue 30/01/06

89 Grosvenor Avenue 03/02/05

89 Grosvenor Avenue 04/10/04

Similar services:

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

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

CARE HOME ADULTS 18-65 Grosvenor Avenue (89) 89 Grosvenor Avenue Carshalton Surrey SM5 3EN Lead Inspector Deborah Yapicioz Unannounced Inspection 25th November 2005 16:00 Grosvenor Avenue (89) DS0000007134.V267552.R01.S.doc Version 5.0 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 Grosvenor Avenue (89) DS0000007134.V267552.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 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. Grosvenor Avenue (89) DS0000007134.V267552.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Grosvenor Avenue (89) Address 89 Grosvenor Avenue Carshalton Surrey SM5 3EN 020 8647 3912 020 8647 3912 manager.grovesnoravenue@careuk.com 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) Care Solutions Limited vacant Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Grosvenor Avenue (89) DS0000007134.V267552.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd February 2005 Brief Description of the Service: 89, Grosvenor Avenue, Carshalton Beeches is owned, managed and staffed by Care U.K. The home is registered to provide residential care for up to five adults with Learning Disabilities. The home is a large semi-detached Edwardian property, which has many original features. There is a large lounge on the ground floor, a kitchen diner as well as an enclosed patio and a large garden. The home has a built on laundry room to the rear of the property. There are four bedrooms on the first floor and one bedroom on the ground floor. The home has an office/ staff sleep in room and storage space on the third floor. The house has its own transport and is well placed for public transport links and is close to Wallington, Carshalton and Sutton town centres Grosvenor Avenue (89) DS0000007134.V267552.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place in the early evening of 26th November 2005. The care home was inspected under the National Minimum Standards Care Homes for Younger Adults. The home manager, Mr William O’Brian was not on duty at the time of the inspection and Claire Langley facilitated the inspection. During the inspection the inspector was able to speak to many of the homes service users. The inspection was spent meeting with Ms Langley, looking at records, talking to service users and a tour of the premises. Information supplied on the pre-inspection questionnaire was also used in writing this report. The inspector would like to thank the service users and the staff team for their help in facilitating the inspection. What the service does well: What has improved since the last inspection? What they could do better: The home is generally homely and comfortable although there is a malodour in one of the bedrooms, which needs to be investigated. The home manager was not on duty at the tome of the inspection and in keeping with company policy the staff team do not have access to the personal Grosvenor Avenue (89) DS0000007134.V267552.R01.S.doc Version 5.0 Page 6 files. A requirement was made at the previous inspection around the Criminal Records Check for the home manager. This requirement will be carried over and assessed at the next inspection. The home manager must also submit an application to register as the home manager with the Commission for Social Care Inspection. The service users files looked at during the inspection did not have recent review information on file. The service users care needs should be reviewed on a six monthly basis with an annual multidisciplinary review. There are still some gaps in the medication records for the home, which is a cause for concern as this was noted at the previous inspection. The manager must take steps to ensure that medication records are correctly filled in at all times. 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. Grosvenor Avenue (89) DS0000007134.V267552.R01.S.doc Version 5.0 Page 7 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 Grosvenor Avenue (89) DS0000007134.V267552.R01.S.doc Version 5.0 Page 8 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): 1,2,3, The home provides information and introduction opportunities for prospective service users and their families to make an informed choice about moving to the home, although a service users guide in a suitable format is still not in place despite a generous timescale for compliance. EVIDENCE: The registered provider has compiled a statement of purpose outlining the aims and objectives of the home, and the facilities and services it provides. This information is given to families and professionals considering a placement at Grosvenor Avenue The service users guide has not yet been completed despite being discussed at the previous three inspections. The service users guide must be in place before the next inspection. The home only accepts referrals following an assessment completed by a care manager. The home also completes an assessment. The home has had one new admission since the last announced inspection and a care manager’s assessment was seen on the service users file. Compatibility with others already living in the home is also taken into account. Flexible visits and overnight stays are arranged for any prospective service users to get a “feel” of the home. Grosvenor Avenue (89) DS0000007134.V267552.R01.S.doc Version 5.0 Page 9 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): 6,7,9 The service users have comprehensive individual care plans with detailed information on their needs and personal goals. Individual care plans include consultation with service users and are regularly updated by the key-worker to reflect current needs. EVIDENCE: Each of the service users has an individual tailored care plan. The care plans are on the service users file and is a record of their aims and goals as well as their achievements. The service users files looked at during the inspection did not have recent review information on file. The home manager must write to the Commission for Social Care Inspection Croydon office with the review dates of each of the service users. The home operates a risk management system and individual assessments are on service users files. Copies of individual risk assessments are kept on the service users file and cover a variety of situations including learning new skills and bathing, using taxi’s and going out in the community. There are also risk assessments relating to the environment and staff under the health and safety at work act. Risk assessments are reviewed regularly. The home also has a comprehensive missing person’s policy, which gives staff clear guidance if a service user was to go missing. Grosvenor Avenue (89) DS0000007134.V267552.R01.S.doc Version 5.0 Page 10 The residents are offered the opportunity to participate in the day to day running of the home and to contribute to the development and review of policies and services through regular meetings and individual discussions with their key workers. A regular service user meeting is held and service users are encouraged to attend and contribute. Grosvenor Avenue (89) DS0000007134.V267552.R01.S.doc Version 5.0 Page 11 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): 12,13,15,16,17 The service users at the home are offered the opportunity to engage in age appropriate activities with an emphasis on using community based facilities. The service users have a varied programme of social activities organised by the staff team to reflect service users individual interests. The daily routines and house rules promote residents’ rights and encourage independence. The home has an open visitors policy to ensure friendships and family links are maintained. Dietary needs are catered for with meals that are nutritionally well balanced, nicely presented, and clearly based on the service users food and drink preferences, providing them with daily variation and healthy eating options. EVIDENCE: The home is supporting service users to access appropriate activities through the day centre programme. The day centres used include The Cheam Centre, Orchard Hill and H.F.T where service users have individual schedules of activities. The home has its own transport and the service users regularly go bowling, to the cinema, and out on day trips. They also use the local shops and cafes. Grosvenor Avenue (89) DS0000007134.V267552.R01.S.doc Version 5.0 Page 12 There is a strong emphasis on service users using the community facilities. The service users have been on an annual holiday and destinations include Butlins, Isle of Wight and Disneyland Paris. The service users are involved in some household tasks such as changing their beds, hovering and washing up. There is an open visitors policy and the home just ask that visitors phone to ensure their family member is going to be in before they visit. The service users also spend occasional weekends at their family homes. Visitors can be seen in any of the homes communal areas as well as the service users bedrooms. The house rules and daily routines are as flexible as possible, bearing in mind the weekday commitments of the service users. The service users are on the electoral register and can vote if they wish to. The home menus are based on the likes and dislikes of the homes service users. They also take into account the service users health issues, for example one of the service users has diabetes and another has small portions on the advise of the dietician. The service users help the staff team to draw up the menus on a weekly basis. They also go shopping with the staff to a local supermarket. The home has a kitchen/diner with enough room for everyone to sit around the dining table although the service users can choose to eat wherever they wish. Grosvenor Avenue (89) DS0000007134.V267552.R01.S.doc Version 5.0 Page 13 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): 18,19,20 Personal care is carried out in a way that residents prefer so that dignity and choice are maintained. Residents’ physical and emotional health needs are detailed in personal plans to offer consist care in this area. EVIDENCE: The home has a policy on the receipt, recording, storage, handling, administration and disposal of medication. It is the homes policy that all medicines administered are recorded on Medicine Administration Record Sheets. During the inspection it was noted that there were still some gaps in the medication records. This is not the first time that gaps have been noted in medication records at the home. The home must ensure all medication records are filled in correctly in future. The level of personal support a service user needs would be detailed at their review and recorded in their personal file. Personal care is provided in private, and timings of this are also flexible. The home provides consistency and continuity through designated key workers All service users are registered with a local General Practitioner. The staff team at the home monitor the health of each of the service users and would ensure they receive any treatment needed. Incident forms are completed following any accidents. Grosvenor Avenue (89) DS0000007134.V267552.R01.S.doc Version 5.0 Page 14 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): 22,23 There is complaints policy and procedure, which facilitates good access to the complaints system for the residents, their family or their representatives. The home has the appropriate policies in place to ensure the protection of vulnerable service users EVIDENCE: The complaints procedure was clear and contained all of the elements required to meet standard 22 including a minimum response time of less than 28 days. The home has a copy of the local authority Adult Protection Policy on site and staff receives training on these issues. Grosvenor Avenue (89) DS0000007134.V267552.R01.S.doc Version 5.0 Page 15 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): 24,30 Overall the general décor of the home is good providing a comfortable, clean and safe environment for service users to live in, however the source of the malodour in one of the bedrooms must be investigated. Service user’s bedrooms provide privacy and reflect individual interests and preferences. EVIDENCE: The home is situated in a residential area between Wallington and Sutton There was suitable domestic lighting and ventilation, There is a large garden at the rear of the home which the service users spend time in during the summer months. Each of the service users in the home has a single room, which is decorated and personalised to reflect their individual taste. The premises were generally bright, airy and clean on the day of the unannounced inspection, however there was a smell in one of the bedrooms. The home manager must investigate the source of the mal odour in the first floor bedroom (at the end of the corridor next to the bathroom) and carry out the necessary steps to eliminate the source. The home has appropriate laundry facilities separate from the kitchen and the preparation of food. The washing machine is capable of washing clothes at high temperatures, which helps with the control of infections. There is also a tumble dryer. The laundry has suitable flooring. There is a locked cupboard for the Grosvenor Avenue (89) DS0000007134.V267552.R01.S.doc Version 5.0 Page 16 Control of Substances Hazardous to Health products. The home has policies and procedures on the disposal of clinical waste. Grosvenor Avenue (89) DS0000007134.V267552.R01.S.doc Version 5.0 Page 17 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): 33 The home is always staffed by at least two members of staff to ensure the service users are supported at all times. EVIDENCE: The home ensues that there are at least two members of staff on duty at any one time. This does not include the home manager. At night there is one waking and one sleep in member of staff. The home manager was not on duty at the tome of the inspection and in keeping with company policy the staff team do not have access to the personal files. These standards will be assessed at the next inspection. Grosvenor Avenue (89) DS0000007134.V267552.R01.S.doc Version 5.0 Page 18 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): 37,39,42 There are clear lines of accountability within the home, which is aimed at ensuring the well being of the service users. In the main health and safety arrangements are adequate to ensure potential risks to service users health and safety are so far as reasonably possible identified and minimised. EVIDENCE: Mr William O’Brian has been recently appointed as the manager of Grosvenor Avenue. Mr O’Brian has worked at the home in various positions since it opened in September 2001. He has completed National Vocational Qualification level two and three and is currently on a National Vocational Qualification level four course. Mr O’Brian must ensure that he submits an application to the Commission for Social Care Inspection to register as the homes manager as soon as possible. Records required for the safety and well being of service users are in place including accidents, water temperatures, complaints, incidents, food records, fire records, service users case files, medication records and so forth. Fire drills are up to date and a fire risk assessment is in place. Fire drills are carried out during the evening as well as during the day. Grosvenor Avenue (89) DS0000007134.V267552.R01.S.doc Version 5.0 Page 19 The staff team attend mandatory health and safety training including moving and handling. The home has regular staff meetings and the registered providers, Care U.k. have introduced service users groups to involve service users in decision- making progress. Copies of the homes policies and procedures are kept in the office Grosvenor Avenue (89) DS0000007134.V267552.R01.S.doc Version 5.0 Page 20 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 3 X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 2 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X X 3 2 X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Grosvenor Avenue (89) Score 3 3 2 X Standard No 37 38 39 40 41 42 43 Score 2 X 3 X X 3 X DS0000007134.V267552.R01.S.doc Version 5.0 Page 21 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 14(2)(a) Requirement The home manager must ensure that service users care needs are reviewed on a six monthly basis with an annual multidisciplinary review. Timescale for action 20/01/06 2 YA37 9(1) (2) 3 YA34 Sch 2. 7b 4 YA20 17 (1)(a)3 3.(I) The registered person must 25/11/05 ensure a ‘suitably’ qualified and competent individual submits an application to register as the homes manager, subject to a fit person interview with the Commission The home must ensure the 25/11/05 Criminal Records Check for the acting manager is available for inspection. The registered person must 25/11/05 ensure medication administration records are correctly filled in at all times. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Grosvenor Avenue (89) DS0000007134.V267552.R01.S.doc Version 5.0 Page 22 No. 1 Refer to Standard YA7 Good Practice Recommendations The inspector recommends that staff at the home do not undertake to become appointees for residents money unless absolutely necessary. Where this is the case, records of all incoming and out going payments are independently audited/monitored by persons not working at the home The service user guide should be put into a format suitable for the service users 2 YA1 Grosvenor Avenue (89) DS0000007134.V267552.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Grosvenor Avenue (89) DS0000007134.V267552.R01.S.doc Version 5.0 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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