Inspection on 20/09/06 for Alma Grove, 1a

This inspection was carried out on 20th September 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 no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Alma Grove, 1a 12/02/06

Alma Grove, 1a 31/01/05

Alma Grove, 1a 12/08/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Alma Grove, 1a Bermondsey London SE1 5PY Lead Inspector Lisa Wilde Unannounced Inspection 20 September & 6 October 2006 11:00 th th Alma Grove, 1a DS0000060222.V311674.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 Alma Grove, 1a DS0000060222.V311674.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. Alma Grove, 1a DS0000060222.V311674.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Alma Grove, 1a Address Bermondsey London SE1 5PY 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 7231 2316 020 7231 2316 billy@odyssey-csft.org www.odyssey-csft.org Odyssey Care Solutions for Today William Conneely Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Alma Grove, 1a DS0000060222.V311674.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th February 2006 Brief Description of the Service: Alma Grove is managed by Odyssey Care Solutions who have other, similar homes in Southwark. The home is a two-storey house in a pleasant residential street in Bermondsey. There is a small garden at the back and on street parking at the front. It is near to small local shops and a larger supermarket. Bus routes pass near to the home, whilst a tube station and main line station are further away. Alma Grove is a home for three men who have learning difficulties and all have their own room. On the day of inspection there were no vacancies. The cost of a place at the home is £1726.66 most of which is paid by social services, the service user pays £62.35 from their benefits. Alma Grove, 1a DS0000060222.V311674.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day in October 2006. The manager was not at the home but the inspector spoke with service users and staff, toured the building and checked records and documents. The manager sent on information to the inspector after the day at the home. Service users said they were happy at the home. This is a very good home. The inspector was just a little worried that things might change because some staff have changed recently and the manager is fairly new. What the service does well: Some things at this home are good • • • • • • • • • • • • • Staff find out what service users want and write this down for them. Staff write plans so they can help service users do what they want to do. Staff help service users make decisions. Staff listen to families and other people who know what service users want. Service users get to go out and do the things they want to do. Service users choose their own food and join in with cooking as much as they are can. Staff make sure service users go to the doctor when they need to. Staff protect service users from people who might hurt them. Service users have their own bedrooms. Service users can decorate their bedrooms how they want to. The home is clean and comfortable. Staff make sure the building is safe. Staff get enough training. DS0000060222.V311674.R01.S.doc Version 5.2 Page 6 Alma Grove, 1a • • • There are enough staff. The organisation checks out new staff before they start working at the home. Staff find out what service users and their families think and put in place plans to make things better. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Alma Grove, 1a DS0000060222.V311674.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 Alma Grove, 1a DS0000060222.V311674.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff make sure that they can meet the needs of service users before they are offered a place at the home. EVIDENCE: There is new legislation in place now that came into force on 01/09/06 and other changes come into force on 01/10/06 which will require services to state exactly what fees each service user is paying and how it breaks down into different areas, in the service user guide. (See Requirement 1) These three service users have lived together for several years and no one new has moved to the home in that time. There is a procedure in place for moving new people to the home that would meet the standard Alma Grove, 1a DS0000060222.V311674.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff write care plans that describe what they will do to make sure that all service users’ needs are met. Care plans are reviewed often enough and plans made to help service users achieve new things. Service users are supported to make understand their choices and make decisions for themselves. Risks are assessed and plans put in place to make sure that any risks are managed, which means that service users are kept safe. EVIDENCE: The inspector looked at two care files and found detailed plans for how staff will support service users in all areas of their lives. The organisation has begun to look at setting goals with service users every three months and at ways of making sure that care is offered in the way service users want. Alma Grove, 1a DS0000060222.V311674.R01.S.doc Version 5.2 Page 10 Staff talked about the different ways in which they support service users to understand choices and make decisions. Risks are assessed and plans put in place to manage those risks. Staff could talk in detail about hw they balance the need to make sure service users are safe with the need for them to be able to rake reasonable risks in their lives. Alma Grove, 1a DS0000060222.V311674.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are supported to do what they want to do and go out when they want to. Service users are part of the local community. Service users choose what they want to eat and staff cook for them. EVIDENCE: Service users have weekly plans in place that ensure they have very full and varied lives. Staff were clear about the need to support service users to go out as much as they choose. Service users in his organisation pay an amount of their benefits towards transport however staff said there is not car or van available to service users at this home. (See Requirement 2) Alma Grove, 1a DS0000060222.V311674.R01.S.doc Version 5.2 Page 12 Staff talked about the communication strategy that this organisation is developing currently and how they hope that this will help staff and service users be more creative in how they support service users. Staff talked about the importance of visual media such as photos, video and DVD. (See Recommendation 1) Staff cook for service users with service users helping as much they can. Menus showed that the weekly meals are fairly varied. Alma Grove, 1a DS0000060222.V311674.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Staff support service users in different ways and service users are encouraged to attend regular appointments to make sure they stay healthy. Medication systems are generally operated effectively so service users know they are getting their medication as they are supposed to. EVIDENCE: Staff talked in detail about the health and personal care details of service users and how they are met by staff. Files showed that records are maintained consistently and accurately. The inspector examined the medication stocks and records and found no problems. There was a previous requirement that the registered person must ensure that the medication administration chart is signed as soon as the medication has been administered. This is now being done. Alma Grove, 1a DS0000060222.V311674.R01.S.doc Version 5.2 Page 14 Alma Grove, 1a DS0000060222.V311674.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 at least once during a 12 month period. 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. Service users know how to complain and their day-to-day concerns are taken seriously and action is taken to make things better for them. Service users are protected from harm by staff receiving training and understanding what to do if they think a service user is being abused. EVIDENCE: The home records formal and informal complaints and comments or concerns. Records are kept of action taken to address any concerns but no dates are recorded of when the investigation or action took place. (See Recommendation 2) Staff talked about the procedures that are in place for protecting service users from harm. Incidents are recorded and sent through to the Commission as required. Incidents are analysed regularly to spot any patterns or trends of concern. Alma Grove, 1a DS0000060222.V311674.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is comfortable, clean and homely throughout. Service users have their own rooms that they have decorated how they choose and the communal areas are large enough. EVIDENCE: There is a lounge and separate activity/games room that staff are hoping to develop further. There is a garden at the back of the house that is well kept. Service users have their own rooms that have been decorated as they choose. Service users said they were happy with their rooms. On the day of the inspection the home was clean and hygienic throughout. The pictures in the home have been in place for a long time and staff did not think that service users had chosen them. (See Requirement 3) There was a previous requirement that the registered person must ensure that there is always toilet paper available in the toilets. This is now done. Alma Grove, 1a DS0000060222.V311674.R01.S.doc Version 5.2 Page 17 Alma Grove, 1a DS0000060222.V311674.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 & 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. All staff hold or are undertaking the NVQ Level 3 in Care and go on extra training which means that they are qualified enough to work with service users. There are enough staff on duty to support service users but not all staff are permanent which means that service users may not be getting consistent support from people who they are comfortable with and who fully understand how to support them. Recruitment procedures are thorough which means that the organisation checks that staff are who they say they are and can do their jobs before they start working at the home. Staff aren’t getting supervision regularly as planed which means that service users may be cared for by staff who are not getting enough support and advice from their managers. EVIDENCE: Alma Grove, 1a DS0000060222.V311674.R01.S.doc Version 5.2 Page 19 There was a previous requirement that the registered person must ensure that all efforts are made to ensure that there is always one permanent member of staff on duty. Staff said that there are always at least two staff on duty. Staff talked about the difficulty recently of two long-term agency staff not being used and being replaced by the organisation’s bank staff who are not known to the team. The manager has also been working at another project for two days a week for the last few weeks and this has been difficult as the previous long-term manager left the home earlier this year. There are two staff vacancies currently, which is the same as at the last inspection although it does not appear that they are the same two vacancies. One permanent staff member has been asked by the organisation to take part in developing the communication strategy, which would mean that they spend half their hours at other services in the organisation. (See Requirement 4) All permanent staff hold the NVQ 3 in Care. The organisation keeps it personnel records at head office and so must keep the Commission’s checklist signed by a Registered Individual at the home. The manager was not available during this inspection so records could not be accessed but the inspector has seen these records at other homes in the organisation so was willing to accept the evidence being sent on after the inspection. Staff said that the basic training required is offered to all staff and that there are several one day or short courses offered in the organisation but not much in depth training to develop staff’s skills. (See Recommendation 3) The supervision schedule showed that some planned supervisions have been missed. The manager contacted the inspector after the inspection to say that September’s supervisions had been completed. Staff said that a form of appraisal has taken place but they were not satisfied that it was thorough enough. The manager sent through the goals/development needs set for staff following the last appraisals and most of these focussed a round the basic training areas, makaton and computer training whereas the two staff who the inspector spent most time with showed a level of awareness and experience that would require a much higher level of training. (See Requirements 5 & 6) Alma Grove, 1a DS0000060222.V311674.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well run. The home conducts reviews of individual service users care and incorporates those reviews into service development. The home ensures that service users views (or the views of their families) underpin the annual review and development of the home. Service users are protected by the operation of effective and robust systems for monitoring health and safety issues. EVIDENCE: The manager moved to this home around six months before this inspection from another home in the organisation. She has not yet put in an application to be registered with the Commission although a senior manager told the inspector later that this is because they are waiting for the Criminal Records Alma Grove, 1a DS0000060222.V311674.R01.S.doc Version 5.2 Page 21 Bureau check to come through. Although there may be external reasons for the delay this is a standard requirement that has to be made. (See Requirement 7) The monthly visits required under Regulation 26 are carried out and sent through to the Commission. The home conducts annual reviews with the service users and completes quarterly returns to the borough organisation that report on identified indicators. There is a local business plan for the home. The home does not yet use an externally accredited quality assurance systems that focuses on the views of service users and the home does not conduct an annual review of the views of family and other stakeholders. The organisation has sent through plans to the Commission and these include how they plan to begin to use the PQASSO system of quality assurance before April 2007. The progress on these issues will be assessed at the next inspection. Health and safety monitoring is regular and thorough. All the required documentation is in place. Alma Grove, 1a DS0000060222.V311674.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 X 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 2 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 4 13 3 14 4 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 3 X 2 X 3 X X 3 X Alma Grove, 1a DS0000060222.V311674.R01.S.doc Version 5.2 Page 23 NO 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 YA1 Regulation 4&5 Requirement The Registered Individuals must ensure that the breakdown of each service users’ fees is put these in the service user guide/statement of purpose as required by the new legislation. The Registered Individuals must ensure that service users are not asked to pay towards transport services that they are not receiving. The Registered Manager must ensure that service users are consulted about the pictures and other decoration in the communal areas of the home to make sure they are what they want. The Registered Individuals must ensure that staff vacancies are filled and there is a permanent and consistent staff team in place. The Registered Manager must ensure that staff receive regular supervision DS0000060222.V311674.R01.S.doc Timescale for action 31/12/06 2. YA13 12 (1) (a) 31/10/06 3. YA24 12 (3) 31/12/06 4. YA33 18 (1) (a) 31/01/07 5. YA36 18 (2) 31/10/06 Alma Grove, 1a Version 5.2 Page 24 as planned. 6. YA36 18 (1) (c) (i) & (2) The Registered Individual must ensure that the annual appraisal is thorough and staff have a full assessment of their development needs as well as of their basic training requirements. The Registered Individual must ensure that the manager puts in an application to be registered with the Commission. 31/12/06 7. YA37 s11 Care Standards Act 31/12/06 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 YA12 Good Practice Recommendations The Registered Individual should consider providing a computer with internet access solely for service users use, along with other visual media equipment to enhance their communication development. The Registered Manager should ensure that the timing of all investigations and actions are recorded in the complaints/concerns records. The Registered Individuals should ensure that additional training programmes are offered that develop the more experienced, long-term staff’s skills and awareness. 2. 3. YA22 YA35 Alma Grove, 1a DS0000060222.V311674.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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. 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