Inspection on 30/01/06 for 89 Grosvenor Avenue

This inspection was carried out on 30th January 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 3 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 25/11/05

89 Grosvenor Avenue 03/02/05

89 Grosvenor Avenue 04/10/04

Similar services:

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

Ashlong House

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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 30th January 2006 11:00 Grosvenor Avenue (89) DS0000007134.V279658.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 Grosvenor Avenue (89) DS0000007134.V279658.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. Grosvenor Avenue (89) DS0000007134.V279658.R01.S.doc Version 5.1 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.V279658.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 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.V279658.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes second inspection for the year 2005/6 and was unannounced. The inspection took place on the morning of 30th January 2006. The home was inspected under the National Minimum Standards Care Homes for Younger Adults. A previous inspection took place on the 30/11/05 2005 when most of the standards that the Commission for Social Care Inspection considers as key standards were inspected. Methods of inspection included a partial tour of the premises, meeting with the service users and the manager, William O’Brian. Records examined included staff and service user records, risk assessments, medication records, complaints, staffing records, and health and safety and fire records. The inspector would like to thank the service users, the staff team and Mr O’Brian for their help in facilitating the inspection. What the service does well: What has improved since the last inspection? What they could do better: Grosvenor Avenue (89) DS0000007134.V279658.R01.S.doc Version 5.1 Page 6 During the inspection it was noted that although there has been some improvement in the recording on Medicine Administration Record Sheets there were still some gaps in the records. The home must ensure all medication records are filled in correctly. There has also been an improvement in the frequency of staff supervisions at the home although they are still not happening as frequently as they should. This will be reviewed at the next inspection. 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.V279658.R01.S.doc Version 5.1 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.V279658.R01.S.doc Version 5.1 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, The home provides information and introduction opportunities for prospective service users and their families to make an informed choice about moving to the home. EVIDENCE: 89 Grosvenor Avenue currently has five service users living at the home. There are four male service users and one female service user aged between 35 and 61. 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. The home manager is in the process of completing the service users guide in a widget format and has confirmed that the service users guide will be available for the next inspection. New Service users are only admitted to the home once a full assessment of their needs; compiled by their care manager or other relevant person has been received. Any new service users to the home will only be considered once compatibility with the current service users is established. Grosvenor Avenue (89) DS0000007134.V279658.R01.S.doc Version 5.1 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 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 and ensure service users wishes are represented. 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 home is in the process of introducing the concept of Person Centred Planning to the review formats. The staff team have all completed training on Person Centred Planning and the majority of service users have now got Person Centred Plans. At the last inspection it was noted that service users reviews had not been completed. Since then the home manager has arranged meetings for all the service users and they have now had a review of their care needs. The home manager must ensure that care needs continue to be regularly reviewed. Grosvenor Avenue (89) DS0000007134.V279658.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): 12,13 The service users at the home are offered the opportunity to engage in age appropriate activities with an emphasis on using community based facilities. EVIDENCE: It is part of the role of the staff team to encourage service users at the home to maintain and develop independent living skills. The service users have a weekly activity timetable and details of the service users weekly commitments are also recorded on service users files. There is a strong emphasis on service users using the community facilities. 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. An aroma therapist visits the home and the service users spoken to during the inspection enjoyed the aromatherapy session. Grosvenor Avenue (89) DS0000007134.V279658.R01.S.doc Version 5.1 Page 11 The home is in the process of planning service users holidays and a variety of destinations have been chosen. One of the service users told the inspector that he wants to go to Florida this year and the staff team at the home are in the process of planning and booking the trip. Other destinations include The Isle of Wight, Spain and Euro Disney Grosvenor Avenue (89) DS0000007134.V279658.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,20 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 service users need varying degrees of assistance with their personal care. The level of support a service user needs would be detailed at review meetings and their preferred routines are set out in their individual Plans. Personal care is provided in private, and timings of this are flexible. The home provides consistency and continuity through designated key workers Healthcare needs were recorded in the service users’ files. All service users are registered with a General Practitioner. Service users have access to relevant professional support to maximise independence, including the Community Team for People with Learning Disability. Two of the service users also attend the Diabetic clinic. Another service user has been referred to the dietician. 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. P.R.N. medication can only be administered with the authorisation of the home manager or the “on call” manager. Grosvenor Avenue (89) DS0000007134.V279658.R01.S.doc Version 5.1 Page 13 During the inspection it was noted that although there has been some improvement in the recording on Medicine Administration Record Sheets there were still some gaps in the records. The home must ensure all medication records are filled in correctly. The home manager informed the inspector that he is in the process of agreeing funeral plans with the service users, their families and their care managers. Grosvenor Avenue (89) DS0000007134.V279658.R01.S.doc Version 5.1 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. There have been no complaints since the last inspection. The home has a copy of the local authority Adult Protection Policy on site. The staff team have attended training on adult protection issues. The staff team are aware of the action they must take if they need to report an incident. Grosvenor Avenue (89) DS0000007134.V279658.R01.S.doc Version 5.1 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. EVIDENCE: 89, Grosvenor Avenue is situated on a residential street within walking distance of Carshalton Beeches Station and Wallington town Centre. Sutton and Croydon town centres are easily accessible by car or public transport. On the day of the inspection the home was comfortable and clean. The home is a substantial Edwardian property, and retains many original features such as an antique fireplace and a tiled hallway with wooden carvings. There are also many “homely” touches such as photographs of the service users through out the house. Each of the service users has a bedroom, which has been personalised to reflect their tastes and interests. Service users spoken to during the inspection said that they liked their bedrooms. There is a crack on the ceiling and the wall of the bedroom on the ground floor. The homes management team is investigating this. Grosvenor Avenue (89) DS0000007134.V279658.R01.S.doc Version 5.1 Page 16 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): 33,34,36 Although the staff team at the home have a range of skills and abilities, which enable them to meet the needs of the service users living at the home, there is a need to ensure that they receive supervision on a regular basis to safeguard the quality of care. EVIDENCE: There are at least two members of staff on duty in the home at any one time. At night there are two sleep in members of staff, one waking and one on call (sleep over). The staff job descriptions were comprehensive in their content and linked to achieving service users goals, as set out in their individual care plans. It is company policy that all new employees are not permitted to start work until two satisfactory references from their previous employees have been confirmed as well as the other information required in schedule two of the care standards act, although the home manager Criminal Records Check was not available as it was held at head office. Two of the staff files looked at during the inspection contained all the necessary information however one of the staff files checked during the inspection did not hold all the references to meet this standard. The home manager must ensure that references are held on all staff files. There has been an improvement in the frequency of staff supervisions at the home although they are still not happening as frequently as they should. This will be reviewed at the next inspection. Grosvenor Avenue (89) DS0000007134.V279658.R01.S.doc Version 5.1 Page 17 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 was appointed as the manager of Grosvenor Avenue in October 2005. He had been the acting manager of the since the previous manager left and 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 informed the inspector that he has recently submitted an application to the Commission for Social Care Inspection to register as the homes manager. There was a clear line of accountability within the home and the manager demonstrated a good knowledge of the service users and the staff team. Grosvenor Avenue (89) DS0000007134.V279658.R01.S.doc Version 5.1 Page 18 The home has self-monitoring systems in place such as a Quality Assurance audit carried out by “Care U.K.”, which takes place every year along with monthly regulation 26 visits. Copies of the visit findings are sent to the Commission for Social Care Inspection, Croydon office. There are regular service users meetings and key worker sessions. The home has also introduced service users meeting s for the local area, which includes a social event. The most recent meeting included a talk on “Safety in The Community” Records required for the safety and well being of service users are in place including accidents, water temperatures, complaints, incidents, food records, fire records, staff and service users case files, medication records and so forth. All staff must attend mandatory health and safety training including moving and handling. The home has a health and safety policy in place. Environmental risk assessments are in place. A first aid box and a fire blanket are situated in the kitchen. There are fire extinguishers throughout the house. Health and safety law posters issued by the health and safety executive were on display. Grosvenor Avenue (89) DS0000007134.V279658.R01.S.doc Version 5.1 Page 19 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 3 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 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 3 34 2 35 X 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 X 2 X 3 X 3 X X 3 X Grosvenor Avenue (89) DS0000007134.V279658.R01.S.doc Version 5.1 Page 20 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 YA34 Regulation Sch 2. 7b Requirement The home must ensure the Criminal Records Check for the acting manager is available for inspection. Timescale for action 30/05/06 2. YA20 17 (1)(a) 33. (I) The registered person must 30/03/06 ensure medication administration records are correctly filled in at all times. The home manager must ensure that all staff receives regular recorded supervisions. 30/05/06 3. YA36 18 (2) 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 YA1 Good Practice Recommendations The service user guide should be put into a format suitable for the service users Grosvenor Avenue (89) DS0000007134.V279658.R01.S.doc Version 5.1 Page 21 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.V279658.R01.S.doc Version 5.1 Page 22 - 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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