Inspection on 13/07/05 for Annaly House

This inspection was carried out on 13th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Annaly House 20/02/06

Annaly House 07/02/05

Annaly House 03/08/04

Annaly House 21/01/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Townley Road, 2-3

Chatsworth Care - Tudor Lodge

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

CARE HOME ADULTS 18-65 Annaly House Old Church, 146a Bedford Hill London SW12 9HW Lead Inspector Davina McLaverty Unannounced Wednesday 13 July 2005 10:30 am th 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 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 Stationary 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. Annaly House G54-G04 S10165 Annaly House V237183 130705 Stage (004).doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Annaly House Address Old Church, 146a Bedford Hill London SW12 9HW Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020-8673-5533 020 8673 8585 Sign the National Society for Mental Health and Deafness Mr Leroy Fitzhubert Kinlocke CRH Care Home 6 Category(ies) of LD Leaning Disability (6) registration, with number MD (E) Mental Disorder Over 65 (6) of places SI Sensory Impairment (6) Annaly House G54-G04 S10165 Annaly House V237183 130705 Stage (004).doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th February 2005 Brief Description of the Service: Annaly House is a six–bedded unit, which provides care for adults who are deaf and have mental health difficulties. It is owned and managed by Sign, which is a charitable organisation. The home is situated in a converted church in Balham (Old Church) and shares the building with the National Deaf Service. Annaly House and National Deaf Services work as an integrated unit within Old Church due to the degree of the mental health issues, challenging behaviours and support needs of the residents. Annaly House is a self-contained unit situated on the second floor of the building. All residents have their own bedroom with sink unit. There is a communal open plan lounge /kitchenette/dining area. The main kitchen is located in the premises of the National Deaf Service on the ground floor. The home is situated in a residential area, which is in close proximity to public transport and local amenities.The home is staffed twenty-four hours a day. The residents and staff communicate using British Sign Language (BSL). Annaly House G54-G04 S10165 Annaly House V237183 130705 Stage (004).doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector, (supported by an interpreter who was used to communicate with the residents and deaf staff), carried out this unannounced inspection. The inspection started at 10.30am and concluded at 4.45pm. The inspector met all six residents and spoke at some length to four residents in their bedrooms. A number of records were examined, which included residents care plans, staff records, staff meeting and residents minutes and health and safety records. All the communal areas in the home were seen. What the service does well: What has improved since the last inspection? Since the inspection, progress has been made to the quality assurance system in place, in that the views of service users have been sought. Premises work identified in one resident’s room had been addressed. Three of the four staff spoken to reported that they felt that communication between hearing and deaf staff had improved and as a result the staff team were working more effectively in delivering the service. Annaly House G54-G04 S10165 Annaly House V237183 130705 Stage (004).doc Version 1.40 Page 6 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. Annaly House G54-G04 S10165 Annaly House V237183 130705 Stage (004).doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Annaly House G54-G04 S10165 Annaly House V237183 130705 Stage (004).doc Version 1.40 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 standard(s) 1, 2, 3 & 4 Residents are provided with relevant information on the service they can expect from the home prior to moving in. Service user assessments are thorough and allow for a detailed care planning system to develop from this documentation. Prospective residents are fully involved in the assessments offering them an opportunity to make choices about their lives. EVIDENCE: A comprehensive statement of purpose and service user guide is available in the home. Both documents provide the resident and their representative with good information about the home and the service they can expect. However, both documents require updating. Since the last inspection no new resident had been admitted to the service. Referrals would normally come to the home from the hospital run by the National Deaf Services who share the same building. The manager described the assessment procedure used prior to admission to the inspector and how the resident and their representative would be involved. Due to the home operating from the same premises where referrals are most likely to come from. The inspector was told that visits would definitely take place and all reports would be made available A detailed care plan is devised. Annaly House G54-G04 S10165 Annaly House V237183 130705 Stage (004).doc Version 1.40 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 standard(s) 6, 7, & 8 The needs of the resident are identified and planned for with involvement of the individual and their key worker. Residents are encouraged by staff to participate in the life of the home and to acquire skills to enhance their lives. EVIDENCE: Three residents care plans were examined. Care plans were individual, reflecting the individual needs of each resident. Care plans focussed on various individual needs of the resident e.g. mental health, budgeting, weight and healthy eating, friendships and relationships, self neglect, aggression, alcohol abuse. The care plans seen detailed the support needed. Daily logs are written which are cross -referenced with the care plans. Monthly evaluations were seen, which focuses on the following areas - Activities, Mental Health, medication, leisure, and behaviour and progress noted. These reports are then used for reviews and Care Planning Approach meetings. The expectation is that the resident is fully involved with their care plans. Key workers and residents signatures were seen on care plans and monthly evaluations. Two of the residents spoken to were aware of their care plans. Residents spoke of what they did in the home e.g. making snacks, doing their laundry, cleaning their bedrooms and of various outings that are arranged. Residents all said that they liked living in the home. A residents’ meeting took place on the day Annaly House G54-G04 S10165 Annaly House V237183 130705 Stage (004).doc Version 1.40 Page 10 of the inspection. Minutes of previous meetings were seen and areas discussed included day trips out, holidays and whether they were all right in the home or had any complaints. Residents spoke of being given choice as to what they did and when they did it. The staff spoken to expressed a degree of frustration at residents not wanting to do a great deal, despite being given a lot of encouragement. They stated that when trips are arranged, quite often residents decide that they no longer wished to go, which they found disheartening. Annaly House G54-G04 S10165 Annaly House V237183 130705 Stage (004).doc Version 1.40 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 standard(s) 11. 12, 13,14,15, & 16 Staff are committed to supporting residents to take up opportunities for engaging in leisure activities, and utilising community facilities according to individual needs and wishes. The home supports residents to make their own decisions and bear their consequences. Family and personal relationships are encouraged. The rights of individual residents form part of individual care planning documentation. EVIDENCE: As previously stated, care planning documentation is comprehensive and individually focussed. Residents attend various activities according to their needs. Staff support residents as required. Residents are encouraged to use the Bridge Day Services (a day centre specifically for deaf and hard of hearing people), where a variety of activities are offered e.g. computing, arts and crafts and trips out as well as the recreational activities available in the hospital on the ground floor. All residents are able to use public transport. Five of the six residents can go out independently. The sixth resident, due to a physical disability, has to be supported to access the community. The manager stated that all residents are registered to vote. Five of the six Annaly House G54-G04 S10165 Annaly House V237183 130705 Stage (004).doc Version 1.40 Page 12 residents have some contact with their extended family. Contact is encouraged and supported by staff if it is what the resident wishes. A communal lounge /kitchenette is available, which all residents have access to. A communal television was observed to be available in the lounge, as well as some board games. The majority of residents had their own television and music equipment in their bedrooms. Holidays are encouraged for those residents who want to travel. Recently, two of the residents went to Disneyland Paris supported by staff and had a wonderful time. One resident spoke about the visit, stating what a good day it was. He stated that a day trip was not sufficient time to see everything and he is planning to go back. The manager stated that two of the residents were in the process of arranging summer holidays. Annaly House G54-G04 S10165 Annaly House V237183 130705 Stage (004).doc Version 1.40 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 standard(s) 18 & 19 None of the current residents in the home required assistance with personal care. The health needs of residents are well met, with evidence of good multidisciplinary working taking place. EVIDENCE: Residents are all registered with local GP’s. The manager stated that staff would advise and support residents in relation to personal care. All residents have a key worker who has specific responsibility for supporting them. Arrangements are in place for residents to receive dental, optical care in the community. The home has good links with the psychiatrists and staff at the National Deaf Service, who in an emergency, can be called upon for advice. Annaly House G54-G04 S10165 Annaly House V237183 130705 Stage (004).doc Version 1.40 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 standard(s) 22 & 23 The home has a clear complaints procedure, a copy of which is detailed in the service user guide, which is given to all residents. Policies and procedures are in place to protect service users from abuse and harm. EVIDENCE: A complaints policy is available at the home, and a copy of who to complain to is displayed on the resident’s notice board. Residents spoken to were aware of the complaint policy and what to do if they were not happy. The manager reported that no new complaints had been recorded since the previous inspection. The home has a clear procedure for dealing with any allegation of abuse. A copy of the placing authorities adult protection procedures was available in the home. Staff spoken to was aware of their responsibility to report any concerns they may have, although no training in this area had been given. Consideration should be given to staff attending training in the protection of vulnerable adults. An organisational whistle blowing policy was seen in the policies and procedures manual. Annaly House G54-G04 S10165 Annaly House V237183 130705 Stage (004).doc Version 1.40 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 standard(s) 24, 25, 26, 27 28 & 30 The standard of décor within the home is good and is comfortable for residents. The home is clean, tidy and hygienic. EVIDENCE: The home was found to be comfortably furnished in a domestic style. The majority of the furnishings seen were of a good quality. The home was decorated last year and residents were involved in choosing the colour of paint for their rooms. Two of the four residents spoken to made reference to needing more space as they had purchased many personal possessions. One resident acknowledged that they needed to sort things out in their room and stop buying things due to the lack of space. The other resident spoke of purchasing shelves to create more space. Bedrooms seen varied in respect of personalisation. All had been personalised, and in many ways reflected the different personalities and individualities of the residents. Residents take responsibility for keeping their bedrooms tidy, although where needed, support from staff is offered. Annaly House G54-G04 S10165 Annaly House V237183 130705 Stage (004).doc Version 1.40 Page 16 All four residents said they were satisfied with their bedrooms. Each room has a flashing doorbell light to alert the residents that someone wants them, however, two were found not to be working. One resident stated that his vibrating pad, to alert him of fire if sleeping, was not working. This was raised with the manager, who stated that residents did not have vibrating pads, as waking night staff are employed. He stated that he would follow this issue up with the resident. The inspector noted that the radiator guard in one of the resident’s bedroom was damaged and required repair. The requirement made at the previous inspection regarding the replacement of a blind and broken window restrictor had been addressed. The communal areas were seen to be as comfortable. Residents have two toilets, one with a bath; the other doubles up as a laundry area. Residents are offered support and encouraged to regularly do their laundry. A separate shower is available. The home was found to be clean and tidy on the day of the inspection. Annaly House G54-G04 S10165 Annaly House V237183 130705 Stage (004).doc Version 1.40 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34, & 35 Staff are knowledgeable of residents needs, but are frustrated with the slow progress being made. Training is high on the organisation agenda, however, no system appears to be in place to ensure that staff receive refresher courses in core areas of training. EVIDENCE: There are always at least two staff on duty at all times. The manager is supernumerary. There is currently one full time vacancy, which is covered by bank staff. Staff reported that the staffing levels are sufficient to meet the needs of the current residents. Regular staff meetings take place, although one staff member stated that “interpreters” are not always booked and therefore the meeting is not as effective as it could be due to the level of signing of some of the staff. The manager acknowledged this as an issue, which he is trying to address. Staff meetings provide a forum for all staff to be kept informed of any issues in the home, which includes any changing needs of residents. It is therefore imperative that there is good clear communication between staff. There is a daily handover of an hour where staff have opportunities to practice their signing skills with each other and with residents. The manager acknowledged that maybe this area needed more attention, in particular, to encourage signing between the deaf and hearing staff. Annaly House G54-G04 S10165 Annaly House V237183 130705 Stage (004).doc Version 1.40 Page 18 Currently, more than half the staff team have obtained their NVQ level 2. The organisation places training high on its agenda. Training records were seen and the inspector noted that some core training e.g. food hygiene, first aid were in need of updating. There appeared to be no clear system in place to ensure that all staff received refresher training. Supervision was seen to be taking place. Two staff spoke positively about supervision and being able to discuss issues with the manager. Three staff files were examined. Only one was complete with all the required information detailed in Schedule 2 of the Care Homes Regulations. Two files had no evidence of staff identity and one had no references. CRB and health clearance was seen on all three. The administrator stated that “Sign Care” a project set up within the organisation, recruited the most recent staff member where the most gaps where noted. This project no longer exists. The administrator stated that references had been forwarded to Signs Human Resources department. The manager was advised to obtain copies of references or written confirmation of all checks carried out with the dates. Annaly House G54-G04 S10165 Annaly House V237183 130705 Stage (004).doc Version 1.40 Page 19 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 The manager is clear of his role. He is a qualified nurse who recently obtained his NVQ Level 4 in management. Opportunities are provided for residents to voice their opinions on how they would like the home to be run. EVIDENCE: Staff spoken to, stated that the manager was “good” and “supportive” and tried to address issues they raised. Staff, however, spoke of the frustration of constantly encouraging residents to try new things only to have them rebuffed, which they found frustrating. In discussion with the manager, he stated that staff found the residents mental health needs very frustrating as well as challenging. Training in mental health awareness is a core course for staff however, the manager stated that staff often underestimated the impact of the length of the resident’s mental health and the effect this had on their lives. He held the view that sustaining the residents out of hospital and encouraging them to make some decisions, be it very small, was an achievement, which should be recognised. He stated that he endeavoured to reinforce this during supervision and staff meetings. Annaly House G54-G04 S10165 Annaly House V237183 130705 Stage (004).doc Version 1.40 Page 20 In respect of health and safety within the home, a monthly check of the premises is carried out and systems are in place to address issues raised. However, part of the requirement made at the previous inspection was still outstanding. Correspondence was seen of the organisations efforts to get the required information regarding legionella test, electrical wiring certificate and gas inspection. However, copies have not been forthcoming from National Deaf Services who are responsible for the premises. The manager said that he is still trying to get the required information. The requirement has been repeated. Annaly House G54-G04 S10165 Annaly House V237183 130705 Stage (004).doc Version 1.40 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 3 3 x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 2 3 3 3 x 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 x Standard No 31 32 33 34 35 36 Score x x 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Annaly House Score 3 3 x 3 Standard No 37 38 39 40 41 42 43 Score x 3 x x x x x G54-G04 S10165 Annaly House V237183 130705 Stage (004).doc Version 1.40 Page 22 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 6 Requirement The Registered Persons must ensure that the Statement of Purpose and Service User Guide is reviewed and updated copies forwarded to the Commission. The Registered Persons must ensure that the following maintenance issues are addressed. The radiator cover in one of the residents rooms is repaired and that the two flashing door lights in residents rooms are repaired. The Registered Persons must ensure that all the information listed in Schedule 2 is available in the home. Where this is not possible written confirmation from Sign human resources department confirming when checks detailed in the schedule were carried out and their outcome.Timescale of the 31/10/04 & 7/2/05 –not fully met The Registered Person must· obtain:A copy of the most recent gas certificate for the premises. Obtain a copy of the test carried out for legionnaires. Timescale for action 30/9/05 2. 25 23(2)(b) 13(4) (c) 30/9/05 3. 34 Schedule 2& 19(1) (b) 13/7/05 & on going 4. 42 13(4) 30/09/05 Annaly House G54-G04 S10165 Annaly House V237183 130705 Stage (004).doc Version 1.40 Page 23 Obtain a copy of the electrical wiring certificate. Timescale of the 30/3/05 not met. 5. 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. 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