Inspection on 04/12/07 for 89 Grosvenor Avenue

This inspection was carried out on 4th December 2007.

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 5 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 30/05/06

89 Grosvenor Avenue 30/01/06

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

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 89 Grosvenor Avenue Carshalton Surrey SM5 3EN Lead Inspector Adrian Gordon Key Unannounced Inspection 4th December 2007 10:00 89 Grosvenor Avenue DS0000007134.V355571.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 89 Grosvenor Avenue DS0000007134.V355571.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. 89 Grosvenor Avenue DS0000007134.V355571.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 89 Grosvenor Avenue Address Carshalton Surrey SM5 3EN 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 8647 3912 020 8647 3912 manager.grovesnoravenue@careuk.com Care Solutions Limited vacant Care Home 5 Category(ies) of Learning disability (0) registration, with number of places 89 Grosvenor Avenue DS0000007134.V355571.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last key inspection 30th May 2006 Brief Description of the Service: 89 Grosvenor Avenue is owned and managed by Care UK and provides residential care for up to five adults with learning disabilities. The home is located in a residential road in Carshalton, close to local shops and amenities with good transport links. The home is not identifiable as a care home and is in keeping with neighbouring houses. Information about the service is available in the Statement of Purpose and Service User Guide. 89 Grosvenor Avenue DS0000007134.V355571.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and carried out over the course of one day by one inspector. It consisted of a tour of the premises, examination of records and observation of care practice. We met with three people who use the service, one member of staff and the manager. Questionnaires were left for staff and people that use the service, but none were returned. Two questionnaire were received from relatives in May 2007. What the service does well: What has improved since the last inspection? What they could do better: The manager must be registered with the Commission to make sure the home is meeting Regulations. This has affected the overall rating for the service. Assessments must be reviewed to make sure that the service is meeting the changing needs of individuals. Care plans must be in a consistent format and be more person centred. The Service User Guide should be updated and in a format which is easier for people with learning disabilities to understand. 89 Grosvenor Avenue DS0000007134.V355571.R01.S.doc Version 5.2 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 89 Grosvenor Avenue DS0000007134.V355571.R01.S.doc Version 5.2 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 89 Grosvenor Avenue DS0000007134.V355571.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service do not have up to date information about the home. Assessments are carried out before admission but these are not up dated. EVIDENCE: The Statement of Purpose was updated in May 2007 and contains all the information required to give a good overview of the service. However, the Service User Guide remains out of date and includes old information on fees. It is also not very easy to read. This does not give people using the service the information they need. The Guide should be updated and thought be given to the use of pictures and photographs to make it more meaningful for people with learning disabilities. New admissions have an assessment completed before coming to live at the home. However, these are not reviewed and kept up to date. Most of the people who use the service have lived at the home for many years. In order to make sure their changing needs are identified, assessments must be updated and kept under review. 89 Grosvenor Avenue DS0000007134.V355571.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans provide the basic information necessary to deliver each individuals care but are not detailed or person centred. EVIDENCE: There is a lot of care and support information for each person that uses the service. However, it is not consistent and some peoples care plans were more detailed than others. Information includes how to support in areas such as dressing, eating, behaviour, mobility and relationships. The details in one care plan were very brief and needed to be more individualised and person centred. The plan also needed to be reviewed as it was written in August 2006. There was good information on how to communicate with one person. In general, the written information needed to be up dated to a consistent format so that it is easier to find and understand. 89 Grosvenor Avenue DS0000007134.V355571.R01.S.doc Version 5.2 Page 10 People who use the service are encouraged to make decisions for themselves. This was seen in practice when one person asked a lot of questions to staff about a party. Staff responded by asking the person what it was they wanted to do. People regularly make choices about their daily lives, for example when to get up and what they want to eat. Staff were aware of individual preferences and the importance of listening to what people want. Risk assessments are in place and cover areas such as behaviour, health and community activities. This helps to make sure that people who use the service are kept safe whilst enjoying individual lifestyles. Risk assessments are reviewed every month although one was seen which was not dated. 89 Grosvenor Avenue DS0000007134.V355571.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are able to enjoy a good range of activities of their own choosing. EVIDENCE: Each person that lives at the home has an individual activity plan. This shows what they do each week. For example swimming, shopping, bowling or a trip to the local pub. Educational opportunities include cooking at an adult education college. Some people also go to day centre. There have been two holidays this year - a choice of the Isle of Wight or Lake District earlier on, then a trip to Butlins in Bognor more recently. Visitors are made welcome and can come to the home at any time. One relative commented that their family member is supported to keep in touch and sends cards and presents on birthdays. 89 Grosvenor Avenue DS0000007134.V355571.R01.S.doc Version 5.2 Page 12 Menus are based on the likes and dislikes of the people that live at the home. They also take into account individual health needs or preferences. The menu is usually done every Saturday for the week ahead. If people don’t want what is on the menu then they are offered an alternative. 89 Grosvenor Avenue DS0000007134.V355571.R01.S.doc Version 5.2 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. 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. Good support is in place from staff and specialists to make sure the health needs of people who use the service are met. EVIDENCE: People who use the service have a ‘Health File’ which gives good information about the health support people need. This includes hearing, diet, mobility and eye sight. Visits to health professionals are noted, such as dentist, doctor and chiropodist. The home has a keyworker system so that individuals have one member of staff who they can form a closer relationship with. This means that their personal preferences are able to be fed back to the whole staff team. There are monthly meetings between individuals and their keyworker although written reports of these meetings do not have much detail and could be more meaningful. 89 Grosvenor Avenue DS0000007134.V355571.R01.S.doc Version 5.2 Page 14 Each person has a medication profile which includes a photograph, details of medication and any allergies. Medication Administration Record (MAR) sheets were filled in correctly and showed no gaps. A record is kept of medication which is given ‘when required’. The local pharmacist last visited the home in September 2007 89 Grosvenor Avenue DS0000007134.V355571.R01.S.doc Version 5.2 Page 15 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. People who use the service are able to express their views and concerns in a safe and understanding environment. EVIDENCE: In questionnaires people said they were aware of how to make a complaint. There have not been no recent complaints. People who use the service are made aware of what they should do if they need to talk to somebody. A copy of the complaints procedure is kept in each bedroom. The service has a copy of the local adult abuse procedures which is kept in the office. Staff were aware of the action to take in the event of any concerns. Training records showed that staff have received up to date training in the Protection of Vulnerable Adults (POVA). There are a good systems in place to make sure the money of people who live at the home is kept safe. A book is held to record each individuals financial transactions. Each entry is signed by two staff. Receipts are kept for each purchase which are numbered and tally with records in the book. 89 Grosvenor Avenue DS0000007134.V355571.R01.S.doc Version 5.2 Page 16 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, 27, 28, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live at the home benefit from living in the clean, homely and spacious environment. EVIDENCE: 89 Grosvenor Avenue is a large property set in a residential street near Carshalton. Accommodation is laid out over two floors with a small office in the attic. Communal areas are on the ground floor, and include a large kitchen/dining area and lounge. These were nicely furnished, clean and bright. To the rear of the house is a large garden and terrace area. There is a shower and toilet room on the ground floor and a bathroom on the first floor. The bathroom needed redecorating as there were some tiles missing around the bath and the sealant was black and mouldy. 89 Grosvenor Avenue DS0000007134.V355571.R01.S.doc Version 5.2 Page 17 Two bedrooms were seen which were large and individualised with pictures and posters. People had there own possessions to enjoy, such as televisions and music systems. The manager said the bedrooms were due to be redecorated and occupants had already chosen the colours they preferred. 89 Grosvenor Avenue DS0000007134.V355571.R01.S.doc Version 5.2 Page 18 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, 34, 35, 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The competent, well trained staff team ensure that people who use the service are well supported. EVIDENCE: The atmosphere in the home is friendly and welcoming. The staff team were observed to treat individuals with dignity and respect throughout the course of the inspection. Recruitment records show that all the necessary checks are carried out before employing a member of staff. These include an Enhanced Criminal Records check and proof of identification. Although references are sought from previous employers, some of these were not on headed paper and had no company stamp. These should be followed up to ensure they are genuine. New staff receive induction to make sure they are aware of the needs of individuals and working practices in the home. The induction process needs to be reviewed to make sure it is in line with Skills for Care guidance. There are 89 Grosvenor Avenue DS0000007134.V355571.R01.S.doc Version 5.2 Page 19 good training opportunities for staff and a training plan shows that core skills training is kept up to date. This includes food hygiene, manual handling and health and safety. Formal supervisions are recorded but do not always happen regularly. For example there was sometimes a gap between supervision of up to six months. Staff said that they are supported by the manager and can approach him at any time if they have any questions or concerns. 89 Grosvenor Avenue DS0000007134.V355571.R01.S.doc Version 5.2 Page 20 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 adequate. This judgement has been made using available evidence including a visit to this service. People who use the service are encouraged to get involved in how the home is run. The manager is not registered with the CSCI. EVIDENCE: The manager is still not registered with the CSCI despite this being a requirement at the last key inspection in May 2006. Failure to do so could result in enforcement action being taken. The manager showed a good understanding of the needs of individuals living at the home and the running of the service in general. There are quality assurance questionnaires which are given to people who use the service for feedback. These have been made easy to use. Feedback about 89 Grosvenor Avenue DS0000007134.V355571.R01.S.doc Version 5.2 Page 21 the results of surveys is given from the Head Office. There is also a Service User Involvement Group for the local Care UK homes which meets once a month. The manager said that most of the people who live at the home will attend. Monthly monitoring visits are carried out by a Regional Manager and reports are kept at the home. Although records show that the necessary health and safety checks had been completed, there was not always evidence that this was so. For example the Portable Appliance Test was done on February 2007 but there was no report. A new fire system was installed in September 2007. Weekly fire point tests and regular fire drills are carried out. Up to date data sheets are kept for hazardous chemicals and the action to be taken in case of any accidents. However, the storage cupboard was not locked which could place people who use the service at risk. 89 Grosvenor Avenue DS0000007134.V355571.R01.S.doc Version 5.2 Page 22 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 2 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 3 26 X 27 2 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 2 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 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 3 X X 2 X 89 Grosvenor Avenue DS0000007134.V355571.R01.S.doc Version 5.2 Page 23 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 YA2 Regulation 14 Requirement To make sure individuals changing needs are being met, the needs assessment must be kept under review. To ensure people’s needs are being met, care plans must be kept up to date and be more person centred. To ensure staff are properly supported, formal supervisions must be given six times a year. The home manager must apply for registration by the Commission for Social Care Inspection. This was a requirement at the last key inspection in May 2006. 5. YA42 13(4) To make sure that all parts of the environment are safe, storage for hazardous chemical must be kept locked. 01/01/08 Timescale for action 01/03/08 2. YA6 15 01/03/08 3. YA36 18(2) 01/03/08 4. YA38 8(1)(a) 01/03/08 89 Grosvenor Avenue DS0000007134.V355571.R01.S.doc Version 5.2 Page 24 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 So that people that use the service have the information they need, the Service User Guide should be updated and put in a format which is easy to understand. The upstairs bathroom should be redecorated to so that people who use the service have a more pleasant environment in which to wash. Induction should be in line with Skills for Care guidance to make sure new staff get the information they need. To make sure that recruitment is as thorough as possible, references which are not on headed paper should be followed up over the telephone. To ensure staff are properly supported, formal supervisions should be given six times a year. 2. YA27 3. 4. YA35 YA34 5. 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