Inspection on 08/11/05 for Bowley Close, 1

This inspection was carried out on 8th November 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Bowley Close, 1 13/12/06

Bowley Close, 1 27/02/06

Bowley Close, 1 01/03/05

Bowley Close, 1 08/11/04

Bowley Close, 1 25/03/04

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Chatsworth Care - Dawson House

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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 Bowley Close, 1 Farquhar Road London SE19 1SS Lead Inspector Ms Alison Pritchard Announced Inspection 10:00 8 November 2005 th DS0000007068.V248976.R01.S.doc Version 5.0 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 DS0000007068.V248976.R01.S.doc Version 5.0 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. DS0000007068.V248976.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Bowley Close, 1 Address Farquhar Road London SE19 1SS 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) 0208 670 0340 Choice Support Mr Mohamed Touit-ha Care Home 1 Category(ies) of Learning disability (1) registration, with number of places DS0000007068.V248976.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st March 2005 Brief Description of the Service: The home provides care for one service user who has lived at the home since it opened in December 1995. The accommodation consists of a ground floor flat located in a cul-de-sac close to the centre of Crystal Palace. There are several other care homes grouped together in the close, all of which are managed by Choice Support. The home is well maintained internally and externally. It is close to local facilities such as shops, cafés, pubs, a park and sports centre. Public transport routes – both buses and trains - are close by. DS0000007068.V248976.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced and took place over one day in early November 2005. The inspection methods included discussion with the Registered Manager, interviewing a member of staff, informal conversations with the resident, a tour of the building and inspection of records. Comment cards were distributed to people involved with the resident. 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. DS0000007068.V248976.R01.S.doc Version 5.0 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 DS0000007068.V248976.R01.S.doc Version 5.0 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: There have been no recent admissions to the home and none are planned. 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. The resident has a licence agreement on file describing the services they will receive. DS0000007068.V248976.R01.S.doc Version 5.0 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 The resident’s needs and preferences are reflected in the care plan. The resident has the chance to contribute to decision making in the home and appropriate people who will promote her best interests are also involved. EVIDENCE: The home is introducing the person centred planning approach to care planning. Care planning goals, were clear, reflected the resident’s wishes and desires and are monitored. There are a number of guidelines in place which support the implementation of these. There is a risk management policy in place. Risk assessments were seen which relate to the resident’s activities which may present dangers to herself or others. They were reviewed recently and were appropriate to maintain safety. 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. DS0000007068.V248976.R01.S.doc Version 5.0 Page 9 Each shift is planned in conjunction with the resident so that the events of the day are in accordance with her wishes and needs. The resident is consulted about decisions about the running of the home and matters of concern to her. An advocate and family members are also involved in such matters. Information is kept securely, with due regard for confidentiality. The managing organisation is registered under the Data Protection Act. DS0000007068.V248976.R01.S.doc Version 5.0 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 The resident has the opportunity to take part in a range of valued activities at home and in the community. Staff supports relationships of value to the resident. The meals reflect the resident’s nutritional needs and preferences. EVIDENCE: The resident takes part in a range of activities in the home and in the community. She attends an art project one day a week. Recent activities have included ten-pin bowling, a boat trip and visits to the cinema; she travels with staff around the local area using public transport. She was accompanied by staff to go on holiday recently and told the inspector that she had enjoyed the trip. Inside the home the resident follows a number of activities including baking, photography, jewellery making and household tasks. The resident is supported to make and receive visits to and from family members and friends. An advocate who has known the resident for a significant period also visits. The visitors’ book is used appropriately. DS0000007068.V248976.R01.S.doc Version 5.0 Page 11 The menu record shows that meals are varied and a range of food is provided, including fresh fruit, vegetables, fish and meat. The resident decides what to eat with the assistance and advice of staff. DS0000007068.V248976.R01.S.doc Version 5.0 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, The health needs the resident are well met with evidence of good multidisciplinary working which has benefited the resident. Overall the medication is well managed but some improvements need to be made to the medication administration record. EVIDENCE: The home has an effective relationship with a local multi-disciplinary health care team which provides specialist care for people with learning disabilities and a member of the team has been working with the resident with a view to providing specialist advice to the home. The resident attends medical appointments and staff support her to follow the advice of health professionals. Overall medication management is good but it was found that the medication administration records needed some improvements. Specifically the forms should include details of the residents’ allergies and Latin abbreviations should not be used to describe when the medication should be given. The homely remedies list has been reviewed by the GP. DS0000007068.V248976.R01.S.doc Version 5.0 Page 13 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 the resident. EVIDENCE: The complaints procedure meets the legal requirements and is included in the statement of purpose. There have been two complaints received since the last inspection, both of which were upheld. The complaints record did not show the outcome of a complaint that the service user had made. Full records of the outcome of complaints and action taken to resolve the issues must be recorded. This was the subject of a requirement of the inspection of March 2005. The resident is aware how to raise complaints and has used the procedure with the support of staff. 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. All of the staff in the home have undertaken training in adult abuse issues. There are appropriate and safe systems in place for checking financial transactions carried out on behalf of the resident. Examination of these records showed that they were in good order and appropriate items are purchased with the resident’s money. DS0000007068.V248976.R01.S.doc Version 5.0 Page 14 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, 26, 27, 28, 30 Residents benefit from a home which is clean, comfortable and homely. Some areas of the home need to be redecorated. EVIDENCE: The living room has been redecorated with the full involvement of the resident. The room is attractive and homely and reflects the resident’s choice. One of the light fittings was broken; it was pointed out to the manager who made the appropriate arrangements for its repair. The resident’s bedroom is attractive and decorated according to her personal taste. There are plans to redecorate the kitchen, bathroom and WC over the next year. This will improve the homeliness of these rooms. The home is satisfactorily clean and laundry facilities are suitable for the home. DS0000007068.V248976.R01.S.doc Version 5.0 Page 15 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, 36 The resident benefits from there being enough experienced and trained staff to provide the care that she needs. The staff are well supported and supervised. The resident benefits from safe recruitment practices. EVIDENCE: There is always one member of staff on duty with the resident at all times. One member of staff provides cover overnight by sleeping in the home. Additional management support is available through the on-call system out of office hours. These staffing levels are in keeping with the resident’s needs. Any vacancies caused by sickness or other members of the staff team generally cover annual leave. This lends consistency to the resident’s care which is an important aspect of her needs. The new member of the team had previously worked at the home on a ‘bank’ basis and has assisted her introduction to the home. A check of records at the head office of the managing organisation showed that recruitment procedures and practice are safe and thorough, contributing to the protection of the resident. Of the two staff members working at the home in addition to the Registered Manager one has achieved NVQ2 and the other is working towards it. All of the DS0000007068.V248976.R01.S.doc Version 5.0 Page 16 staff have undertaken recent training in values applicable to the provision of good quality care. The Registered Manager on a monthly basis provides staff supervision. Minutes showed that there has been a gap in the frequency of staff meetings but that these have now resumed. This is an additional source of support for the team who most often work alone. DS0000007068.V248976.R01.S.doc Version 5.0 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, 38, 39, 41, 42, 43 Management systems contribute to effective monitoring of standards of care and incorporate the views of residents. Health and safety matters are well managed in the home. EVIDENCE: The Registered Manager holds a Diploma in Management Studies and NVQ Level 3 in independent living. He has substantial experience of working with service users who have learning disabilities and challenging needs and is very familiar with the needs of the resident of this home. The management style was described as supportive and the inspector was informed that he is open to suggestions for developments of the service to the benefit of the resident. 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. The manager is conducting an audit of the filing system to ensure that the systems are appropriate and efficient. DS0000007068.V248976.R01.S.doc Version 5.0 Page 18 There are good arrangements in place for health and safety management in the home. A fire risk assessment was seen and was dated 11th June 2005. Weekly checks are conducted of the fire alarm system and water temperatures. Regular fire drills are conducted, with the most recent having taken place on 19th October 2005. Other aspects of health and safety are subject to risk assessment. There is a business plan in place for the managing organisation which includes objectives for the overall service. DS0000007068.V248976.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x 3 3 Standard No 22 23 Score 2 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 x 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score x 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score 3 3 3 x 3 3 3 DS0000007068.V248976.R01.S.doc Version 5.0 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 YA22 Regulation 17(2) sch4 para 11 Requirement The Registered Person must ensure that the complaints record includes details of the outcome and the action taken by the Registered Person in respect of any complaint. The previous timescale of 01/06/05 is not met and a new timescale is set. The Registered Person must ensure that the medication administration record does not include Latin abbreviations in the instructions for administration of medication. The Registered Person must ensure that the medication administration record includes information about the resident’s allergies. Timescale for action 01/02/06 2 YA20 13(2) 01/02/06 3 YA20 13(2) 01/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. DS0000007068.V248976.R01.S.doc Version 5.0 Page 21 No. Refer to Standard Good Practice Recommendations DS0000007068.V248976.R01.S.doc Version 5.0 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 DS0000007068.V248976.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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