Inspection on 11/11/05 for Bowley Close, 3

This inspection was carried out on 11th 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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Bowley Close, 3 01/09/06

Bowley Close, 3 10/11/04

Bowley Close, 3 02/03/04

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 Bowley Close, 3 Farquhar Road London SE19 1SZ Lead Inspector Ms Alison Pritchard Unannounced Inspection 2.20pm 11 November 2005 th DS0000007062.V254345.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 DS0000007062.V254345.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. DS0000007062.V254345.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Bowley Close, 3 Address Farquhar Road London SE19 1SZ 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 761 4461 Choice Support Mr Nihal De Silva Wijeyeratne Care Home 4 Category(ies) of Learning disability (0), Learning disability over registration, with number 65 years of age (0), Mental disorder, excluding of places learning disability or dementia (0) DS0000007062.V254345.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 4 people with learning disabilities and mental disorder, some of whom may be over 65 years of age 1st July 2005 Date of last inspection Brief Description of the Service: 3 Bowley Close is a purpose built bungalow. It is in a quiet cul-de-sac near Crystal Palace and is part of a small complex of registered care homes, managed by Choice Support and maintained by Hyde Housing Association. It is registered to support four adults who may have both learning and physical disabilities. The home has four large single bedrooms, a shower room and a bath room, both with adaptions for people with physical disabilities. There is a large living room and an accessible garden on two sides of the home. There is ample on road parking and the home is close to bus and British Rail transport links. It is also close to local resources such as shops and leisure facilities. All these facilities are reached via a steep hill. There were no vacancies at the time of the inspection. DS0000007062.V254345.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and carried out over the afternoon of a mid November day. The inspection methods included discussion with the Registered Manager and with care staff, a tour of the building and examination of records. As none of the residents talk direct communication was not possible but care practice was observed in an effort to reach an assessment of whether they are settled in the home. 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. DS0000007062.V254345.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 DS0000007062.V254345.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, 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. A licence agreement was seen on one resident’s file describing the services they will receive. DS0000007062.V254345.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, 10 Residents benefit from a care planning system which is used to set goals and which is reviewed regularly. A system to conduct regular audits of files would be useful in ensuring that residents benefit from the recording and monitoring systems in the home. Care needs to be taken to ensure accurate recording of residents’ personal details. Residents would benefit further if full information was included in care plans about how care needs will be addressed. EVIDENCE: The home is introducing the person centred planning approach to care planning. The care plan for one resident was examined. A person centred planning meeting was held for one resident during the week prior to the inspection and a goal had been identified for the resident from the meeting. It was found that the information available for the resident included a range of documents, some were recent and current and there were other older documents which it would be useful to review to assess their current relevance. A system to conduct regular audits of files would be useful in DS0000007062.V254345.R01.S.doc Version 5.0 Page 9 ensuring that residents benefit from the recording and monitoring systems in the home. There were inconsistencies on the file regarding the resident’s racial background. The resident’s racial background was recorded differently in two different places on the file. The error would have important implications for the provision of culturally sensitive care. A document which included a checklist of cultural needs had a number of aspects of care identified, however there were no details recorded about how the help should be provided. For example there were no details about how the staff should assist the resident to follow her religion and celebrate festivals although this had been ticked as a need. 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. Information is kept securely, with due regard for confidentiality. The managing organisation is registered under the Data Protection Act. DS0000007062.V254345.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, Links with the community are good and support residents’ social interests. Residents are supported to maintain relationships of importance to them. EVIDENCE: The residents take part in a range of activities and in the community. The activities followed include attendance at day centres, a café project, swimming, bike riding, an art project, a theatre group and using local pubs. In the home residents have a range of leisure equipment available such as musical items, and sensory equipment. Three of the four residents went on holiday to Centre Parcs during the summer. The need for aids and adaptations prevented the fourth resident joining the group. Further consideration should be given to how her needs for a holiday can be met, exploring specialist provision where these items will be available. The residents are supported to maintain contact with family members. An advocate also visits. The visitors book is used appropriately. DS0000007062.V254345.R01.S.doc Version 5.0 Page 11 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 communal parts of the building. DS0000007062.V254345.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 Residents benefit from personal support which is appropriate to their needs. Residents’ health care needs are promoted by the home. Some improvements are needed to the systems for the management of medication . EVIDENCE: The principles of privacy, dignity, independence and self-determination form part of the philosophy of the managing organisation. The residents were all observed to be well dressed and groomed during the Inspection. Staff interactions with residents were warm, friendly and caring. During a tour of the building it was noted that continence management products were stored indiscreetly, this was pointed out to a member of staff who agreed to ensure that they were stored with more regard for the person’s privacy and dignity. There is a visual aid used to show which staff members are on duty. Those residents who can use the aid would find this useful to ensure that they have information about who is to care for them. Other communication aids used are objects of reference. A programme for their use was seen, it was dated May 2004. It was not in current use but the reason for this was unclear, it would be useful to review the document to assess if it is currently relevant for the resident. DS0000007062.V254345.R01.S.doc Version 5.0 Page 13 There was evidence of good contact with the GP and appropriate referrals to health care professionals, such as the speech and language therapy service. All of the staff have been trained to administer medication. The GP has reviewed the medication, both those given regularly and that given on an ‘as needed’ basis. Medication is stored safely. The medication administration records showed that some improvements to the home’s medication systems are necessary. For instance one resident was given some medication which is given on an ‘as needed’ basis on two occasions during the week of the inspection. While the reasons for the administration was recorded on the reverse of the medication administration record (MAR) the signature of the person who had administered it was not completed on the front of the record. On some documents Latin abbreviations had been used in relation to the administration of medication, this is inappropriate. There was one item of medication which had to be exposed fourteen days after opening. It was noted that an open packet of it had not been dated and this could be unsafe. These matters were pointed out to staff so that they could be addressed without delay. DS0000007062.V254345.R01.S.doc Version 5.0 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. 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. The Registered Manager provides training for staff in adult protection issues. DS0000007062.V254345.R01.S.doc Version 5.0 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, 26, 27, 28, 29, 30 The residents benefit from a building which is clean and comfortable. Although most areas are homely some staff notices were inappropriately displayed in the living room. The specialist facilities meet the needs of the residents. EVIDENCE: There is sufficient communal space for the needs and numbers of residents. It was noted that some staff notices were displayed in the living room, this is not appropriate and they should be moved to be displayed in the office. There is an accessible garden for the use of residents of the home. The bedrooms are adequate in size and personalised. The building is homely, comfortable and clean. The Registered Manager informed the inspector that the building has been assessed by an Occupational Therapist who is a specialist in the needs of people with a visual impairment. As a result some changes have been made to the building and its facilities to take account of the needs of the residents. The specialist equipment available to residents include appropriate lighting, handrails, an adjustable bed with safety rails, hoists, a bath aid and shower chair. DS0000007062.V254345.R01.S.doc Version 5.0 Page 16 DS0000007062.V254345.R01.S.doc Version 5.0 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 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): 33, 34 There are enough experienced and trained staff to provide the care that the residents need. Recruitment procedures contribute to the protection of residents. EVIDENCE: There are no vacancies in the staff team which is made up of, in addition the Registered Manager, one Assistant Team Manager, nine full time care staff and two part time care staff (who work 27 hours and 29 hours respectively). Two of the care staff work only at night time. During the waking day there are three members of staff on duty, and at night there is a member of staff awake in the building. On call support is available as necessary. A check of Choice Support recruitment records showed that the procedures followed are safe, thorough and comply with the legal requirements. DS0000007062.V254345.R01.S.doc Version 5.0 Page 18 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): 39, 41, 42 Management systems contribute to effective monitoring of standards of care, although further attention is needed to maintain residents’ files in good order. Health and safety matters are well managed in the home. EVIDENCE: 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. As noted at standard 6 a system to conduct regular audits of files would be useful in ensuring that residents benefit from the recording and monitoring systems in the home. Health and safety systems were found to be in good order at the last inspection although an immediate requirement was made which related to the supply of hot water in a WC. This problem has now been addressed. DS0000007062.V254345.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 x 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 3 x 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 2 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score x x 3 3 x x CONDUCT AND MANAGEMENT OF THE HOME x 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 x x 3 x 2 3 x DS0000007062.V254345.R01.S.doc Version 5.0 Page 20 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 YA6YA41 Regulation 15(1) Timescale for action The Registered Person must 01/05/06 ensure that a system to conduct regular audits of files is introduced to ensure that residents benefit from the recording and monitoring systems in the home. The Registered Person must 01/02/06 ensure that the systems for dealing with medication are improved by ensuring that: • the records of the administration of medication given on an ‘as needed’ basis include a signature. Latin abbreviations are not used in the instructions for administration of medication. medication which has a limited shelf life is labelled with the date of opening. Requirement 2 YA20 13(2) • • DS0000007062.V254345.R01.S.doc Version 5.0 Page 21 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 YA14 Good Practice Recommendations The Registered Provider should ensure that consideration is given to how one resident’s needs for a holiday can be met, exploring specialist provision where items such as hoists will be available. The Registered Provider should ensure that staff notices are not displayed in areas used by residents. 2 YA24 DS0000007062.V254345.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. 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