Inspection on 01/04/08 for Admiral House

This inspection was carried out on 1st April 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Admiral House 12/01/09

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 Admiral House 22 Thrale Road Wandsworth London SW16 1PA Lead Inspector Louise Phillips Key Unannounced Inspection 1st April 2008 09:45a Admiral House DS0000070451.V361403.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 Admiral House DS0000070451.V361403.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. Admiral House DS0000070451.V361403.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Admiral House Address 22 Thrale Road Wandsworth London SW16 1PA 07980 211927 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) rajdooraree@hotmail.com Admiral Healthcare Ltd Mrs Kavita Goolaub Care Home 10 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10) of places Admiral House DS0000070451.V361403.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following categories of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Mental Disorder, excluding learning disability or dementia - Code MD The maximum number of service users who can be accommodated: 10 Date of last inspection N/A Brief Description of the Service: Admiral House is a registered care home for up to ten residents, aged 18-65 years, with mental health needs. The service has two owners, one who is the Responsible Person and the other the Registered Manager. The home is a four-storey house and each resident has a single room with ensuite, or with bathing facilities in close proximity to their room. There are a number of communal areas for the use of residents. There is a small car parking area to the front, and a large garden to the rear of the house. The home is close to transport links that provide access to the shopping areas of Streatham, Tooting and Mitcham. At the time of the inspection the fees for the service ranged from £900 to £1500 per week. Admiral House DS0000070451.V361403.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 over one day with time spent talking to the manager/ owner of the service. This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The service has been registered with the CSCI since October 2007, but has not admitted any residents to the service during this time. Therefore the inspection consisted of discussion with the manager, a tour of the premises and viewing relevant paperwork. Due to there being no staff or residents at the service the key standards for younger adults could not be inspected properly, and this is reflected in the report. All the key standards will be assessed thoroughly at the next inspection. What the service does well: What has improved since the last inspection? What they could do better: There are a number of areas where the home needs to make improvements, particularly to ensure that residents living at the home will be adequately protected. Requirements have been made to guide the home to meet these improvements by way of staff training, thorough recruitment checks on new staff, safe working practices and appropriate health and safety checks. Please contact the provider for advice of actions taken in response to this Admiral House DS0000070451.V361403.R01.S.doc Version 5.2 Page 6 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. Admiral House DS0000070451.V361403.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 Admiral House DS0000070451.V361403.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 and 2 Quality in this outcome area is good. The service has good written information that enables potential residents to make a choice about whether they would like to move to the home. The plan for residents moving to the home is thorough and individualised to ensure that the home can adequately meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a statement of purpose and service users guide that describes what new residents can expect from living at Admiral House and the aims of the service. During the inspection the manager showed a copy of a new brochure for the service, which includes photographs of the home and facilities. Since registering with the CSCI no residents have moved in to the home. The manager spoke about ongoing difficulties in admitting residents, and of the efforts she has been making with a number of relevant professionals in Wandsworth local authority. She also spoke about links she has made to establish what residential mental health services are needed in the borough. With this information she has adapted the rehabilitation aims of the service, to Admiral House DS0000070451.V361403.R01.S.doc Version 5.2 Page 9 provide a structured programme to promote daily living skills for residents to move to more independent accommodation. The manager said that some prospective residents have visited the service, but that no assessments have been carried out yet, due to the need to clarify funding arrangements with Wandsworth. The manager showed the documents that will be used to carry out an assessment of potential residents, which includes a pre-admission assessment format and mental state assessment. There is also a statement of terms and conditions for use with new residents. Admiral House DS0000070451.V361403.R01.S.doc Version 5.2 Page 10 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 and 9 Quality in this outcome area is good. The care planning processes allow each resident to be fully involved in identifying their needs and planning their care with the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a care plan format in place to record the care required for each resident. The manager discussed that once a resident moves into the home an initial care plan will be put in place and that this will be reviewed after the first month once the resident decides to stay. This will then be developed to incorporate all the care and support needed by the resident whilst they are at the home. The manager stated that the resident will be fully involved in this process and that the care provided will be individualised to each person’s needs. The manager also showed a number of other documents that will be used to compile important information about residents. These include appropriate formats for risk assessment and recording key-working sessions. Admiral House DS0000070451.V361403.R01.S.doc Version 5.2 Page 11 The documentation also includes a format to record each resident’s wishes in relation to the possibility of their becoming terminally ill and what they would like to happen in the event of their death. Admiral House DS0000070451.V361403.R01.S.doc Version 5.2 Page 12 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 and 17 Quality in this outcome area is good. The home aims to promote the individual needs and interests of the residents, providing support where necessary to enable them to develop skills to live more independently. This judgement has been made using available evidence including a visit to this service. EVIDENCE: These standards could not be properly assessed on this occasion due to no residents currently living at the service. These standards will be assessed thoroughly at the next inspection. The manager stated that activities for residents will be tailored around their individual needs, interests and hobbies. She said that residents will also be expected to participate in the intense rehabilitation programme planned for the service, which will include them being involved in cooking, cleaning and decision-making in home. The aim of this is to promote the residents Admiral House DS0000070451.V361403.R01.S.doc Version 5.2 Page 13 independence in carrying out daily activities with aim to move to less supportive accommodation. She further described that a priority would be to orientate new residents to the local area so that they are familiar with the community facilities and accessing public transport. Through accompanying residents with this the owner and manager discussed that they would be able to assess any risks that could occur as a result of residents going out and about, where they would provide support as necessary. Admiral House DS0000070451.V361403.R01.S.doc Version 5.2 Page 14 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 and 20 Quality in this outcome area is adequate. The home has appropriate policies in place for the safe administration of medication. Staff must receive training prior to giving out medication. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 18 and 19 could not be assessed on this occasion, and will be inspected at the next inspection. There are a number of policies relating to the safe administration of medication in place at the home. There are also a number of forms in place for the management of medication, including Medicine Administration Record (MAR) chart and formats for recording the receipt and disposal of medication. There is also information describing the use and side-effects of commonly used medications used to treat mental health issues. The manager stated that if residents coming to the home manage their own medication they would encourage them to continue with this, and that they Admiral House DS0000070451.V361403.R01.S.doc Version 5.2 Page 15 would carry out a risk assessment to ensure that the resident can manage this without their support. Each bedroom also contains a lockable drawer where the medication can be stored safely. The Registered Persons must ensure that all staff working at the home receive training in the safe administration of medicines prior to them giving any medication t residents. Admiral House DS0000070451.V361403.R01.S.doc Version 5.2 Page 16 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 and 23 Quality in this outcome area is adequate. There is a satisfactory complaints procedure. Some improvements are needed to ensure that residents living at the home will be adequately protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints procedure that contains all the relevant information, and a copy of this is included in both the Service Users Guide and Statement of Purpose. There is a book in place to record any complaints received. The home has developed in-house policies in relation to Protection of Vulnerable Adults (POVA). Further work is required in this area by the home obtaining a copy of the local authority POVA procedures, and also ensuring that all staff working at the home undertake POVA training. Admiral House DS0000070451.V361403.R01.S.doc Version 5.2 Page 17 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 and 30 Quality in this outcome area is adequate. The standard of the décor within the home is of a good standard and presents as an attractive and environment for residents. Further improvements are needed to ensure the safety of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Admiral House is a large bright house, airy and spacious throughout. On entering the home there is a hallway that is tastefully decorated, warm and inviting. A tour of the building shows that a good standard of décor continues throughout. A number of improvements have been identified as needing attention to ensure the safety and comfort of residents who move to the home: • The plastic panel on front door needs replacing, as it is loose and is a security risk. DS0000070451.V361403.R01.S.doc Version 5.2 Page 18 Admiral House • • • • • • • • • • All the plastic windows throughout the building need to be replaced with appropriate glass. Rubbish needs to be removed from all external areas of the home. The hole at the top of the exterior wall to left of building (when looking out) needs to be made good. The external cupboard containing the gas meter needs to be repaired. Paintwork on the external windowsills needs to be made good. The fence that runs between Admiral House and house number 24 needs replacing. Chipped glass window in the front ground floor bedroom window needs to be replaced The kitchen area is in need of modernising. Damp areas in the basement are in need of addressing. The rear garden area is in need of making good. Admiral House DS0000070451.V361403.R01.S.doc Version 5.2 Page 19 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 and 35 Quality in this outcome area is adequate. The home must ensure that appropriate checks are carried out on staff prior to employment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: These standards could not be properly assessed on this occasion, due to no staff having been employed at the service yet. At present there is only the manager/ owner employed at the service. She holds application information for a number of potential staff, and she said that she has carried out interviews, but that they are unable to start because there being no residents due to move to the service yet. There are a number of documents in place that are being used for the recruitment of staff, such as application forms, interview record forms, job offer letters, contract and reference request forms. There is also a supervision contract and supervision recording form, and a record to list any training undertaken. Admiral House DS0000070451.V361403.R01.S.doc Version 5.2 Page 20 The manager said that induction will be provided by the home and that training for staff will be accessed through external training courses. Admiral House DS0000070451.V361403.R01.S.doc Version 5.2 Page 21 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 and 42 Quality in this outcome area is good. The manager is experienced and has a clear understanding of the service aims. Improvements need to be made by the implementation of health and safety checks to maintain the safety of the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has a number of years experience in managing and providing a care service to people with mental health needs. She has worked in different care settings and she is currently undertaking the NVQ Level 4 in Management to enhance her skills. She demonstrated a good awareness of the areas of development needed for the service and working within the legislation in relation to running a care home. Admiral House DS0000070451.V361403.R01.S.doc Version 5.2 Page 22 The home has devised quality assurance questionnaire for residents, relatives, visitors and healthcare professionals to complete. The manager said that the aim is to carry this out monthly, along with monthly residents meetings. The questionnaire asks for comments on the home environment, care received, food, facilities, etc. The manager stated that the feedback will be used to improve the service and address any concerns that may arise. The manager/ owner needs to ensure that systems are in place to ensure safe working practices at the home. These include ensuring that all staff employed have undertaken training in first aid, lifting and handling, fire safety, food hygiene and infection control. Routine checks also need to be commenced on the fridge and freezer temperature, hot water temperature, Legionella testing, etc, to ensure the safety of those living at the home. A record and certificates (where appropriate) must be maintained of all health and safety checks carried out at the home. Admiral House DS0000070451.V361403.R01.S.doc Version 5.2 Page 23 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 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 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 X X 2 X 3 X 3 X X 2 X Admiral House DS0000070451.V361403.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? N/A 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 YA20 Regulation 13(2) 18(1)(a) Requirement The Registered Persons must ensure that all staff working at the home receive training in the safe administration of medicines. The Registered Persons must ensure that all staff working at the home have received training in the Safeguarding of Vulnerable Adults (SOVA). The Registered Persons must obtain a copy of the local authority SOVA procedures. 3. YA24 13(3)(4), 16(c),23 The Registered Persons must address all environmental issues as detailed below: • The plastic panel on front door needs replacing, as it is loose and is a security risk. All the plastic windows throughout the building need to be replaced with appropriate glass. Rubbish needs to be removed from all external areas of the home. Version 5.2 Page 25 Timescale for action 30/06/08 2. YA23 13(6) 30/06/08 30/09/08 • • Admiral House DS0000070451.V361403.R01.S.doc • • • • • • • • The hole at the top of the exterior wall to left of building (when looking out) needs to be made good. The external cupboard containing the gas meter needs to be repaired. Paintwork on the external windowsills needs to be made good. The fence that runs between Admiral House and house number 24 needs replacing. Chipped glass window in the front ground floor bedroom window needs to be replaced The kitchen area is in need of modernising. Damp areas in the basement are in need of addressing. The rear garden area is in need of making good. 30/05/08 4. YA34 Schedule 2 Sch 4 (6) The Registered Persons must ensure that all information required by the Care Homes Regulations 2001 is obtained for all staff prior to employment. The Registered Persons must ensure that all staff working at the home receive training in first aid first aid, lifting and handling, fire safety, food hygiene and infection control. The Registered Persons must commence routine check of fridge and freezer and hot water temperatures, electrical installation, heating systems, etc. and a record maintained of all these checks. 5. YA35 13(4)(c) 30/09/08 6. YA42 13(4), 23(2)(c) 30/04/08 Admiral House DS0000070451.V361403.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Admiral House DS0000070451.V361403.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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. Extracts may not be used or reproduced without the express permission of CSCI Admiral House DS0000070451.V361403.R01.S.doc Version 5.2 Page 28 - 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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