Inspection on 29/12/05 for 124 Brook Drive

This inspection was carried out on 29th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

124 Brook Drive 26/08/09

124 Brook Drive 18/06/07

124 Brook Drive 24/08/05

124 Brook Drive 10/06/04

124 Brook Drive 11/03/04

Similar services:

Agar Grove & St Augustine`s Alcohol Treatment & Rehab

Herbert Street

Haven (The)

Charis

Hartley House

Rugby House Project

City Roads Crisis Intervention

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

CARE HOME ADULTS 18-65 Equinox, 124 Brook Drive Kennington London SE11 4TQ Lead Inspector Ms Rehema Russell Unannounced Inspection 29th December 2005 09:30 DS0000007019.V273461.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 DS0000007019.V273461.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. DS0000007019.V273461.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Equinox, 124 Brook Drive Address Kennington London SE11 4TQ Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 7820 9924 020 7735 9511 brian@brookdrive@equinox.org.uk Equinox Care Home 14 Category(ies) of Past or present alcohol dependence (0), Past or registration, with number present drug dependence (0) of places DS0000007019.V273461.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 14 patients persons aged 18 years and above, undergoing detoxification from substance misuse day care facilities for up to 4 persons, aged 18 years and above, to receive medication only, for detoxification from substance misuse 24th August 2005 Date of last inspection Brief Description of the Service: Equinox Brook Drive is a large Victorian building in a residential street. It is a short walking distance from a shopping centre which has transport and recreational facilities. The building has three floors plus a basement and the detoxification unit occupies the majority of the ground floor. The basement has offices; the ground floor has the detoxification unit for 14 persons (bedrooms, bathrooms, toilet, medication room, lounge, dining room), reception/staff room, and a separate area of interview rooms; the first floor has the main kitchen, large dining room, communal lounge, women-only lounge, quiet room, toilets and offices; and the top floor has the hostel bedrooms. The detoxification unit provides a 10-day detoxification programme for both drugs and/or alcohol detoxification in regimes that are adjusted to meet individual needs, offering a full nursing assessment and also a general practitioner who is on the premises for four mornings per week. The unit provides high quality accommodation and food, a non-judgemental ethos, group work, access to complimentary and other therapies and an experienced and multidisciplinary staff team. Once the programme is completed, residents have the opportunity to access the 21-day assessment programme in the hostel upstairs. DS0000007019.V273461.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place in the morning of 29th December 2005. The inspector spoke with the manager, cook, several substance misuse workers briefly, several detoxification service users briefly, one substance misuse nurse in depth and one hostel service user in depth who had just completed the detoxification programme. The inspector also looked at documentation and observed the main office, ground floor lounge and first floor dining room. 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. DS0000007019.V273461.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 DS0000007019.V273461.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): All of the above Standards were assessed at the previous inspection. Prospective service users are given clear written and verbal information on which to make an informed choice and they have their needs and aspirations fully assessed. Each service user has an individual support agreement and licence agreement, which state the terms and conditions within the home. The nature of the service precludes trial visits. EVIDENCE: Standards 1 to 5 inclusive were assessed at the previous inspection of 24/8/05 and were all found to be met. The systems have not been altered since that inspection and new service users continue to receive a brochure, welcome pack, licence agreement and support agreement. The welcome pack includes the House Rules, and information in regard to pets, visitors and any other restrictions. A full needs assessment for potential service users continues to be carried out and the home continues to implement and complete a thorough admission procedure. Due to the nature of the service provided (first stage detoxification), prospective service user visits continue to be inappropriate. DS0000007019.V273461.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): 9 Standards 6, 7 and 8 were assessed at the previous inspection. Service users’ assessed and changing needs are reflected in their individual plans. Service users are supported and encouraged to make decisions about their lives and are regularly consulted on all aspects of life in the home. Service users are supported to take risks within the parameters of the detoxification programme. EVIDENCE: Systems in regard to care plans, decisions other than those affected by the House Rules and agreed programme restrictions, and service user participation and consultation, have not changed since the previous inspection. Standards 6, 7 and 8 therefore continue to be met. A risk assessment for every service user is completed on admission, covering areas such as suicide, mental health, violence, arson, sexual behaviour, physical health and housing. If any risk is identified on admission, a full assessment is undertaken on how the risk is to be managed. Each detailed risk assessment then forms part of the service user’s care plan and is regularly reviewed. Service users are given information on how to manage risks and recognise triggers during group work sessions and the twice daily individual sessions with their key worker or other substance misuse worker. DS0000007019.V273461.R01.S.doc Version 5.0 Page 9 In regard to missing persons procedures, the risk of absconsion forms part of the initial assessment and the choice of whom to inform is discussed with the service user, as is appropriate to the aims and objectives of the home’s programme. It is explained to service users that they are not permitted to leave the home for more than 4 hours without permission, and that if they do this and return they will be discharged. In these cases, or if a service user does not return to the home within 24 hours, the referral agency is informed. DS0000007019.V273461.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): 16 Standards 11,12,13,15 and 17 were assessed at the previous inspection. Service users have full opportunities for personal development. Service users are able to take part in activities and the local community within the restrictions of the home’s programme. Personal and family relationships are restricted in keeping with the home’s aims and objectives. Service users are offered a healthy diet and enjoy their meals. Service users’ rights and responsibilities are respected and supported. EVIDENCE: The whole programme at the home is aimed towards giving service users the opportunity to learn coping mechanisms and about relapse management and life skills i.e. how to maintain and develop social, emotional, communication and independent living skills without dependence on addictive substances. At the previous inspection it was found that service users have opportunities for personal development, mix with the local community, engage in appropriate leisure activities, have appropriate personal relationships and are offered a healthy and very popular diet. There had been no changes in these areas since the previous inspection and so these Standards continue to be met. DS0000007019.V273461.R01.S.doc Version 5.0 Page 11 In regard to service users’ rights and responsibilities it was found that these are respected and supported, within the parameters of the detoxification programme. Service users are able to get up when they please in the morning, limited only if they need to take medication at prescribed times and by the expectation to attend 11.30 a.m. group sessions. Breakfast can be taken at any time. Lunch and dinner are served at set times but there is a microwave facility so that service users can choose to consume their meals at other times. The only restrictions to service users’ rights and responsibilities are those dictated by the detoxification programme and explained on admission. For example, service users must adhere to the medication times in order to establish a routine as opposed to the chaos of using and post is opened in the presence of staff to prevent the possibility of substances being obtained/sent. Service users are also encouraged and supported to develop skills and responsibilities via allocated household tasks, such as loading the dishwasher or helping with cooking. DS0000007019.V273461.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 Standards 19 and 20 were assessed at the previous inspection. Service users’ physical and emotional health needs are met. Service users are protected by the home’s policies and procedures for the storage, administration and recording of medication. Appropriate personal support is given in a manner that promotes the dignity and independence of service users. EVIDENCE: The service continues to have a General Practitioner on site for four mornings each week, ensuring that all service users are medically assessed on admission and at other times, and that the detoxification process is closely monitored. Any other healthcare facilities needed e.g. dentist, chiropodist, optician, continue to be arranged by the staff or by the service users themselves, and the home continues to offer complimentary therapies on site. Service users do not require personal physical support but some service users may need verbal prompting in regard to physical hygiene and physical hygiene management. Service users confirmed that any such prompting is given in a manner that safeguards their independence and dignity, and handled sensitively if it is discussed in communal meetings. If service users require or would benefit from physiotherapy, speech therapists, osteopathy etc., these are arranged by the key worker via the GP and appointments facilitated by the DS0000007019.V273461.R01.S.doc Version 5.0 Page 13 home. Service users retain the same key worker for the whole month of the detoxification programme and every third day the daily sessions are conducted by the service user’s key worker. The key worker can therefore co-ordinate the daily information gathered and the care plan and arrange for appointments and follow-up on personal support requests. DS0000007019.V273461.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): 23 Standard 22 was assessed at the previous inspection. Service users’ views are listened to and acted upon. Service users are protected from abuse, neglect and self-harm. EVIDENCE: At the previous inspection it was found that all complaints are recorded, thoroughly investigated, appropriate action taken and complainants’ satisfaction noted. This system had not changed and so Standard 22 continues to be met. There have been no allegations of abuse at the home but the manager and staff spoken with were fully aware of the different forms of abuse that may occur and the procedures to be followed in response to suspicion of evidence of abuse or neglect. Complaints and whistle-blowing procedures are read and signed for during staff induction and two months prior to this inspection adult protection procedures were discussed at team day. Service users’ mood swings and behaviours are discussed and noted daily at handovers and staff spoken with were trained in how to manage verbal or physical aggression. All service users access their money on a daily basis and staff do not withdraw money on behalf of service users. DS0000007019.V273461.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, 29 and 30. Standards 25 – 28 were assessed at the previous inspection. Service users live in a homely, comfortable and safe environment. Bedrooms meet individual needs and toilets and bathrooms provide sufficient privacy. There is suitable and sufficient shared space and the home is clean and hygienic throughout. Aids and adaptations are provided to maximise service users’ independence as required. EVIDENCE: The home’s premises are accessible, safe and well maintained. It has its own private entrance off the street and a ramp and stairs to the front door. CCTV cameras are used to ensure security, but only at the entrance and outside areas of the home so that they do not intrude on the privacy of service users. There is an open window/hatch at the reception office by which anyone wishing to enter the home can be vetted before being allowed in. There is no garden by area of the car park has been paved over, making a pleasant seating area with pergola, where service users can relax in the sun and where barbecues are held. Full transport facilities are available within a few minutes walk of the home and the home has its own vehicle which has been adapted for wheelchair use. This transport is used for service users’ appointments and evening meetings and also for day trips and outings. All communal areas are bright, DS0000007019.V273461.R01.S.doc Version 5.0 Page 16 attractive and comfortable with high quality décor, furniture and fittings. There are framed pictures and ornamentation throughout the home, including positive images of other cultures. There is a ramp to the entrance of the home, and as the outside seating and pergola area is on ground level it is mobility accessible. The home provides one bedroom on the ground floor which is completely adapted for disability and there are suitable aids and adaptations in bathrooms and toilets to facilitate disability access. A service user with mobility restrictions would therefore have access to all of the facilities in the detoxification unit. The home employs a fulltime housekeeper and two fulltime cleaner/handypersons, who keep the home at a very high standard of hygiene and cleanliness, despite the nature of the programme and the constant turnover of service users at the home. DS0000007019.V273461.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): 32 and 34. Standards 31, 33 and 35 were assessed at the previous inspection. Staff are clear about their roles and responsibilities and service users are supported by qualified staff and an effective staff team. Service users’ needs are met by appropriately trained staff. Staff described a thorough recruitment procedure but evidence was not made available at the home despite a requirement from the previous two inspections. EVIDENCE: Staff continue to be clear about their roles and responsibilities, to be suitably trained and to provide an effective staff team, as found at the previous inspection. Staff are also appropriately trained. The home has 6 qualified nurses, plus the Nurse Manager who is a RMN. Half of the 8 substance misuse workers have completed NVQ 3 in Promoting Independence, which is suitable to the aims and objectives of the home. The remaining 4 substance misuse workers are in the process of obtaining NVQ Level 3. The home has therefore exceeded the recommended 2005 NVQ Level 2 training target. The Manager described the robust recruitment practices operated by the Responsible Person, which include only employing a worker after a full Criminal Record Bureau check had been obtained and the POVA list checked. However, Regulation 17 (2) requires registered homes to maintain records specified in DS0000007019.V273461.R01.S.doc Version 5.0 Page 18 Schedule 4 to be available at all times for inspection. Point 6 of Schedule 4 relates the employment records but although the two previous inspection reports have required the Registered Provider to maintain evidence of employees CRB checks at the home, this had not been implemented at the time of this inspection. Following contact with the Registered Provider subsequent to the inspection however, the evidence was supplied and an assurance given that this requirement will be implemented. DS0000007019.V273461.R01.S.doc Version 5.0 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 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 Standards 37, 38 and 42 were assessed at the previous inspection. Service users benefit from a well run home and from the leadership and management approach of the home. Service users views are regularly sought and acted upon. The health, safety and welfare of service users are promoted and protected. EVIDENCE: The management structure and personnel at the home had not changed since the previous inspection and therefore Standards 37 and 38 continue to be met. Similarly, the health, safety and welfare of service users continues to be protected, as was found at the previous inspection. There are several ways in which service users’ views are sought and acted upon by the home. Two service user groups are held each week, chaired by the Registered Manager, at which service users views on any aspect of life at the home are sought, suggestions and complaints acted upon, minutes kept and follow-up action fed back at the next meeting. Two group work sessions are held each day at which issues can be raised, and service user surveys are carried out in the form of exit interviews at the end of the programme. It is DS0000007019.V273461.R01.S.doc Version 5.0 Page 20 recommended that the results of these surveys are printed up annually to fulfil the recommendation of Standard 39.4. In addition to seeking service users’ views, the home obtains feedback on its programme through the GP’s attendance at the weekly management meeting and by staff attending each borough’s Primary Care Team treatment and care groups. The inspector was told that the Divisional Manager carries out the monthly Regulation 26 visits but no evidence of this could be provided at the home on the day of inspection although evidence was subsequently provided by the Divisional Manager. However a requirement has been made for the Registered Provider to ensure that copies of these monthly reports are maintained at the home. DS0000007019.V273461.R01.S.doc Version 5.0 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 X X X X X Standard No 22 23 Score X 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 4 X X X X 3 4 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X 4 X 1 X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 X X X Standard No 37 38 39 40 41 42 43 Score X X 1 X X X X DS0000007019.V273461.R01.S.doc Version 5.0 Page 22 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 YA34 Regulation 19(5)(d) 17(2)&(3) Requirement Timescale for action 31/03/06 2 YA39 26(5) The Registered Person must ensure that a list of relevant CRB information regarding all staff employed at the home is kept permanently at the home. Previous timescales of 30/04/05 and 31/10/05 were not met but the information has been sent to the Commission subsequent to this inspection and an assurance given that this requirement will be implemented. The Registered Person must 31/03/06 ensure that copies of monthly Regulation 26 reports are kept at the home. 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 39 Good Practice Recommendations The results of exit interviews should be collated and DS0000007019.V273461.R01.S.doc Version 5.0 Page 23 printed up annually. DS0000007019.V273461.R01.S.doc Version 5.0 Page 24 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 DS0000007019.V273461.R01.S.doc Version 5.0 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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