Inspection on 26/09/05 for Banyard Road, 40

This inspection was carried out on 26th September 2005.

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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Banyard Road, 40 31/07/07

Banyard Road, 40 07/06/06

Banyard Road, 40 01/03/06

Banyard Road, 40 08/02/05

Banyard Road, 40 31/08/04

Banyard Road, 40 03/03/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

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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 Banyard Road, 40 40 Banyard Road Bermondsey London SE16 2YA Lead Inspector Alison Pritchard Unannounced Inspection 26th September 2005 01.15p DS0000007108.V250244.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000007108.V250244.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000007108.V250244.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Banyard Road, 40 Address 40 Banyard Road Bermondsey London SE16 2YA 0207 231 4774 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) Choice Support Care Home 3 Category(ies) of Learning disability (3) registration, with number of places DS0000007108.V250244.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th February 2005 Brief Description of the Service: The home is registered to provide care for three people who have learning disabilities. The home is managed by a ‘not for profit’ organisation called Choice Support (Southwark) which manages a significant number of care homes for people with learning disabilities in the borough of Southwark and elsewhere. The home is in a cul de sac in Bermondsey, close to Southwark Park where parking is available during daylight hours. It is indistinguishable as a care home. Other local facilities include a shopping centre, market, pubs, cafés and churches. The home is close to public transport routes. DS0000007108.V250244.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and carried out between 1.15pm and 5pm on a day in late September 2005. The three residents were at home during the inspection. Inspection methods included discussion with staff members, observation of care practice, informal conversation with a resident, a tour of the building and examination of records. What the service does well: 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. DS0000007108.V250244.R01.S.doc Version 5.1 Page 6 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 DS0000007108.V250244.R01.S.doc Version 5.1 Page 7 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, 4, 5 The admission policy ensures that the home gathers enough information about a potential resident to make a decision about the suitability of the placement. EVIDENCE: Although there have been no recent admissions to the home, the policy of the managing organisation is to obtain assessments for potential residents prior to their admission. They also encourage introductory visits to the home. The first twelve weeks of a placement are regarded as a trial period, after which a review meeting would be held and the suitability of the home as a long-term placement assessed. Each of the residents has a licence agreement on file describing the services they will receive. DS0000007108.V250244.R01.S.doc Version 5.1 Page 8 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, 8, 9, 10 A system to conduct regular audits of files should be introduced to ensure that residents benefit from the recording and monitoring systems in the home. EVIDENCE: One care plan was examined in detail. Regular meetings had been held with a range of multi-disciplinary staff and the resident’s advocate. The purpose of the meetings was to ensure that the resident’s changing needs were reflected in care practice and that there was general agreement about the on-going suitability of the placement. The file examined was in poor order with papers relating to different issues placed out of chronological order. Some documents on care plan files were undated, others were wrongly filed and some were in need of review to assess their current relevance. An audit of the files is required so that the management of information is improved. There are plans to introduce a ‘person centred planning’ system to the home. Staff have undertaken training in this topic over the last year. DS0000007108.V250244.R01.S.doc Version 5.1 Page 9 Those residents who are able to participate in decision making processes are encouraged to do so, advocates and family members are involved in care planning meetings so that they can represent residents’ interests if they are unable to directly contribute. Choice Support runs a group called ‘Customer Watch’ for residents to contribute feedback to the organisation and to provide a forum for regular discussion. This allows residents’ views generally to be part of the organisational planning. There is a risk management policy in place to support residents’ participation in activities which may involve risk. Some risk assessments seen on a resident’s file were in need of review. Information is kept securely, with due regard for confidentiality. The managing organisation is registered under the Data Protection Act. DS0000007108.V250244.R01.S.doc Version 5.1 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16, 17 Links with the community are good and support residents’ social and educational opportunities. Residents are supported to maintain relationships of importance to them. Meals in the home are good and include a range of fresh items and reflect cultural needs. EVIDENCE: Two of the residents join in activities in the local community and have opportunities for personal development. The activity levels of the third resident have reduced as a result of ill health. Staff ensured that they spent individual time with her in activities which reflected her interests and needs. On the day of the inspection one of the residents had been out to a cookery class. Other activities which this resident follows include attendance at a social club, a music class and art and craft activities. There were plans for one of the DS0000007108.V250244.R01.S.doc Version 5.1 Page 11 other residents to go ten pin bowling. One of the residents was due to go on holiday to Centre Parcs shortly after the inspection. A range of leisure materials are available in the home including specialist items for a service user who has multiple disabilities. Those service users who have contact with family members are supported to maintain links through visits and telephone calls. Visiting is possible at all reasonable times of day. Staff were observed to talk to residents with respect and kindness. They are aware of residents’ need for privacy and respectful of this. Residents have unrestricted access to all parts of the building, this is facilitated by the passenger lift. The food stocks included a range of food including fresh fruit and vegetables. The meal planned for the evening was salmon and vegetables. Residents are encouraged to join in meal preparation when this is possible. The menu showed that residents’ cultural needs are included in the menu planning systems. DS0000007108.V250244.R01.S.doc Version 5.1 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, 21 Residents benefit from personal support which is appropriate to their needs and provided with respect and regard for privacy and dignity. Residents’ health care needs are promoted by the home and medication is well managed. One resident whose needs have increased has benefited from the care and consideration to ensure that her best interests are promoted. EVIDENCE: The principles of privacy, dignity, independence and self determination form part of the philosophy of the managing organisation. The staff team is all female as is the resident group allowing same gender care to be provided at all times. The residents were all observed to be well dressed and groomed during the Inspection. Staff interactions with residents were warm friendly and caring. There has been considerable involvement of a range of health care professionals who have contributed to the on-going care planning for a resident whose needs have increased. DS0000007108.V250244.R01.S.doc Version 5.1 Page 13 Medication is stored safely and records showed that it is managed safely. There was documentation in place signed by the GP to support the use of homely remedies and to confirm changes in medication. The home has managed well the increasing needs of a resident, ensuring appropriate multi-disciplinary involvement and advocacy to ensure that the resident’s best interests are promoted. Funeral plans are on residents’ files. DS0000007108.V250244.R01.S.doc Version 5.1 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 The complaints and vulnerable adults procedures contribute to the protection of residents. EVIDENCE: The complaints procedure meets the legal requirements and is included in the statement of purpose. No complaints have been received in the twelve months prior to the inspection. The adult protection policy of the managing organisation is suitable for its purpose. There have been no investigations carried out under the adult protection procedures in the last year. There are appropriate and safe systems in place for checking financial transactions carried out on behalf of residents. DS0000007108.V250244.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 28, 30 The residents benefit from a building which is clean, comfortable and homely, although the communal landing is in need of redecoration The facilities meet the needs of the residents. EVIDENCE: There is sufficient communal space for the needs and numbers of residents. The communal space consists of a living room and a large kitchen-dining room, both on the ground floor. There is an accessible garden to the rear of the home. The bedrooms are adequate in size and personalised. The building is very homely, comfortable and clean. It was noted that the communal landing has not been decorated for some years and is looking rather dated. The decorating schedule is requested in a requirement of this report. DS0000007108.V250244.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 There are enough experienced and trained staff to provide the care that the residents need. Recruitment procedures contribute to the protection of residents. EVIDENCE: Several members of the staff team have worked at the home for a number of years and are familiar to the residents and with their needs. On the day of the inspection there were three people on duty in the morning, with the acting manager working between 10am and 5pm. In the afternoon until the evening there were three people on duty until 5pm and two until the evening. One member of staff sleeps in the building overnight. On call support is available as necessary. The organisation has an NVQ training programme in place. Information on the team’s achievement of NVQ 2 should be forwarded to the CSCI for inclusion in the final report. Additional training undertaken by staff over the last year includes the following topics – person centred planning; dementia; challenging behaviour; first aid; moving and handling and cerebral palsy. A check of Choice Support recruitment records showed that the procedures followed are safe, thorough and comply with the legal requirements. DS0000007108.V250244.R01.S.doc Version 5.1 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 The home has not had a registered manager since January 2004. This is a breach of regulation which potentially places residents at risk. Checks of the fire alarm and emergency lighting systems are not carried often enough and are not recorded consistently. EVIDENCE: The managing organisation has not submitted an application for the registration of a manager despite the previously registered manager having left in January 2004. This must be addressed by the Registered Provider without delay. The residents have benefited from the considerable good will of staff who have been covering management duties since the post has been vacant. Visits by managers have been carried out as required by regulation 26 of the Care Homes Regulations. Copies of the reports are kept in the home and are sent to the CSCI as required. DS0000007108.V250244.R01.S.doc Version 5.1 Page 18 Health and safety management has improved in the home since the last inspection in that a fire risk assessment is now in place. However the weekly checks of the fire alarm system are carried out somewhat erratically. The records of the checks were kept in two different places and the last recorded check was on 6th September 2005, nearly three weeks before the inspection. The last recorded test of the emergency lighting system was on 22nd March 2005. A query about the efficiency of the fire doors was followed up after the inspection and resolved. DS0000007108.V250244.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 3 3 x 4 3 5 3 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 x 28 2 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 3 LIFESTYLES Standard No Score 11 3 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 4 1 x 3 x x 2 x DS0000007108.V250244.R01.S.doc Version 5.1 Page 20 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 YA6 Regulation 15(1) Timescale for action The Registered Person must 01/04/06 ensure that an audit of residents’ files is conducted to ensure documents are dated, signed and currently relevant. The Registered Person must 01/04/06 ensure that risk assessments are subject to regular review. The Registered Person must 01/04/06 ensure that the decorating schedule for the year ahead is submitted to the CSCI. 01/04/06 The Registered Person must submit an application for the registration under the Care Standards Act 2000 of a manager of the home. This requirement was made in the report of the Inspection of August 2004 and has been repeated at subsequent inspections. Consideration will be given to legal action if compliance is not achieved. The previous timescale of 01/05/05 is not met. A new date for compliance is set. Requirement 2 3 YA9 YA28 13(4)(b) 23(2)(d) 4 YA37 8 DS0000007108.V250244.R01.S.doc Version 5.1 Page 21 5 YA42 23(4)(c)(v) The Registered Provider must 01/03/06 ensure that checks of the fire alarm system and emergency lighting are carried out each week and the results recorded. The previous timescale of 01/04/05 is not met. A new date for compliance is set. 6 YA42 17(2)sch4 para 14 The Registered Person must ensure that only one recording system is used for the recording of fire safety checks. 01/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000007108.V250244.R01.S.doc Version 5.1 Page 22 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. Extracts may not be used or reproduced without the express permission of CSCI DS0000007108.V250244.R01.S.doc Version 5.1 Page 23 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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