Inspection on 28/11/05 for Chadwin Road (81-83)

This inspection was carried out on 28th November 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Chadwin Road (81-83) 05/08/08

Chadwin Road (81-83) 06/12/06

Chadwin Road (81-83) 30/06/05

Chadwin Road (81-83) 29/11/04

Chadwin Road (81-83) 19/07/04

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 Chadwin Road (81) 81 Chadwin Road Plaistow London E13 8ND Lead Inspector Nurcan Culleton Unannounced Inspection 28th November 2005 11:30 Chadwin Road (81) DS0000058206.V269174.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 Chadwin Road (81) DS0000058206.V269174.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. Chadwin Road (81) DS0000058206.V269174.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Chadwin Road (81) Address 81 Chadwin Road Plaistow London E13 8ND 0207 474 8378 0207 474 8378 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) Consensa Care Limited Mrs Chipo Kiss Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places Chadwin Road (81) DS0000058206.V269174.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th June 2005 Brief Description of the Service: 81 Chadwin Road is one of a group of homes owned and managed by Consensa Care and situated in a residential area off the A13. It provides support for three people with severe or enduring mental illness who have twenty-four hour support needs. Whilst the placement is permanent, support is offered with the aim to encourage service users towards independent living. The service does not cater for service users with with organic brain disease, learning difficulties or dementia. People with a history of serious risk to themselves or others or who require high levels of nursing care are also not accepted. The home is next door to 83 Chadwin Road, registered under the same organisation for the same number and category of service user. The service users from both homes often socialise and engage in activities together. The two homes are in the process of being merged and into and registered as one home. The previously acting manager is now approved as the Registered Manager. Chadwin Road (81) DS0000058206.V269174.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 on 28th November 2005. Two service users were living in the home with one vacancy at the time of inspection. The inspector interviewed the Registered Manager, one staff member and, two service users and toured the premises. The inspector also sought evidence from documents and records including service users files and staff files. At the time of inspection, both service users were in the home and were due to go out to their day centre facility. What the service does well: What has improved since the last inspection? One service user moved into their flat in October this year, demonstrating that the home is able to fulfil its aims and objectives of supporting service users towards independent living. Further improvements include the attendance of both service users to the Tulip day centre, a specialist day care provision for people with mental health problems. Service users now receive regular inhouse psychotherapeutic input which has been shown to benefit them. The Registered Manager devised a questionnaire for service users to choose the decoration of the home, which was duly undertaken following the consultation. A policy and procedure and consent form has been developed for service users to go on holiday. Chadwin Road (81) DS0000058206.V269174.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Chadwin Road (81) DS0000058206.V269174.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Chadwin Road (81) DS0000058206.V269174.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 Service users needs are assessed prior to admission. Service users ‘test’ the home through a visit and a trial stay prior to admission. Service users have individual written contracts. Service users must have written information about the home prior to and following admission. The home has demonstrated its capacity to meet service users’ individual needs. EVIDENCE: Requirements were made at the previous inspection for the Statement of Purpose and Service Users’ Guide to be available for inspection. These were examined and were satisfactory containing all required information, with the exception that the Statement of Purpose needs amendment to state that 7 staff members are employed in the home, not 8, as stated in the Statement of Purpose. Service users pre-admission assessments were seen in files. Records seen and discussion with the Registered Manager demonstrated that the home has the capacity to meet individual needs. This is evident from the development of comprehensive care plans in response to assessed needs; liaison with multi-disciplinary professionals and the support received by service users to meet the objectives set in the Statement of Purpose, such as to assist and enable service users to meet their full potential and strive towards independent living. Service users are able to visit the home prior to their admission. Signed service users’ contracts were seen in files. Chadwin Road (81) DS0000058206.V269174.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, 10 Service users know their assessed needs, which are outlined in their individual plans. Service users are involved in making decisions about their own lives and of the activities in the home. The home has a positive ethos to risk taking in service users’ lives. EVIDENCE: Social work assessments and the homes’ pre-admission assessments were available in files. Service users’ care plans were comprehensive and detailed. They contained service users’ identified needs, the desired outcome in the plan and the action required to meet the objective. Care plans examined were signed by the service users. Other essential service users’ documents were signed by them. Records showed that service users are involved in decisions made in the home. The home runs monthly residents meetings and minutes seen showed active consultation with service users. All service users are involved in communal meal preparation, shopping such as for milk, bread and newspapers; gardening and cleaning. Service users participated in a questionnaire to gage their views on how the home should be redecorated. The home was decorated according to their wishes. Risk assessments were seen in files, though the format of the form used could be improved. Service users are supported to undertake activities which encourage the development of their independent living skills. This showed a positive attitude towards risk taking. Chadwin Road (81) DS0000058206.V269174.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 Personal growth and development is encouraged. This is evident in group and individual leisure and learning activities. Personal friendships and family contact are encouraged and maintained. Service users’ rights and responsibilities are respected. EVIDENCE: Service users’ files examined and discussion with the Registered Manager and service users showed that appropriate leisure interests are pursued.Service users are given opportunities for personal development. An activities book was inspected containing daily logs of group activities including swimming, group outings, dancing, bowling, meals out, picnics and parties. A mini-bus is available to the home. Service users resident in the house are Christian and a weekly church service is provided by a visiting local pastor. Personal development is encouraged through sessions in budgeting, meal preparation with one to one support and assistance with shopping. Service users are encouraged to attend college courses and are waiting for courses to commence. Service users presently attend a day centre called ‘Tulip’ in Newham for people with mental health needs. Chadwin Road (81) DS0000058206.V269174.R01.S.doc Version 5.0 Page 11 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 Service users’ wishes regarding the personal support they receive are respected and maintained. Service users’ physical and emotional health needs are met. Service users’ medication is handled appropriately. EVIDENCE: Individual Plans outline personal support needs including service users’ wishes. An appointment diary registered all health appointments and a variety of appointments are maintained, including clinic appointments for depot injections, dental appointments, smoking clinic, hospital and GP appointments and CPA meetings. Emotional support is offered by staff as well as regular sessions with an in-house Psychologist. The Registered Manager informed that this input has been very beneficial to service users. The Boots (M.D.S) medication system is used. The MAR sheets examined were in order. Presently the home administers medication to the service users though support staff are encouraging service users to administer their own medication in the long term. Service users’ files contained signed statements regarding their views on arrangements in the event of illness or death. Chadwin Road (81) DS0000058206.V269174.R01.S.doc Version 5.0 Page 12 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 Service users’ views are encouraged, listened to and acted upon. There is a satisfactory complaints policy, however the Adult Protection Policy could be improved by expanding the procedures expected to be followed by staff. EVIDENCE: The complaints policy and book was examined. There were no recorded complaints in the book. The Registered Manager informed that no complaints had been expressed by the service users. This was confirmed by service users directly. The complaints policy is appropriate and written in a format accessible to service users. It was seen displayed in service users’ rooms. Staff spoken to said that service users were satisfied with the service. Whilst service users spoken to raised some issues concerning their needs in the home, overall they informed that they were happy with the service and support they received by staff. Service users informed that they knew how to complain and that the issues they raised were responded to in most cases. The Adult Protection policy was examined. This policy document could be improved and expanded to further specify what procedures staff should follow in the event of an Adult Protection incident. Service users’ personal financial accounts were examined and deemed to be accurate. Chadwin Road (81) DS0000058206.V269174.R01.S.doc Version 5.0 Page 13 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 The environment is suitable to meet service users’ needs. Bedrooms are personalised and service users live in a clean, homely environment. Some bedroom drawer units need to be replaced or repaired and the panel of the bath also needs to be replaced or repaired. EVIDENCE: The home was clean, tidy and free of odour at the time of inspection. Service users each have their own bedrooms. Two bedrooms were seen. Bedrooms were clean with personalised items shown to the inspector, including personal possessions and items of furniture. Service users are encouraged to maintain and clean their own rooms. Service users’ rooms were painted according to their own choice of colour. The home has been recently decorated in consultation with service users. A previous requirement was made for window restrictors to be installed or for a risk assessment to be in place. Window restrictors were seen during a tour of the rooms. Some bedroom drawer units require repair or replacement in service users’ rooms. One drawer unit would not close properly and one was stiff and difficult to open. Service users share a lounge, a kitchen and a bathroom. The panel of the bath in the bathroom was peeling and needs replacement or repair. The Responsible Individual must ensure that the premises, equipment and furniture used by service users is kept in good repair. Chadwin Road (81) DS0000058206.V269174.R01.S.doc Version 5.0 Page 14 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): 31, 32, 33, 34, 35, 36 Service users benefit from staff who are committed to their task and the needs of the service users. Staff are clear about their roles and responsibilities. Staff are well supported and supervised to understand and respond to the needs of the service user group. The organisation must ensure that training is provided to all employed staff. Some staff personnel records are required. EVIDENCE: The Registered Manager informed that the staff group are committed to providing a quality service for service users and care about the needs of the service users. There is a good team spirit and communication among staff. Seven permanent members of staff are employed in the home (the Statement of Purpose states there are eight staff members). Bank staff are used to cover staff abscences. One member of staff plus the acting manager is on duty at all times. A wake-in staff member is on shift at night. The staff member interviewed spoke positively of their work experience. She confirmed that she had received induction and she was adequately supported to know her duties and responsibilities and received regular supervision. Service users reported that they were treated well and with respect by the staff and their needs were responded to. The Registered Manager informed that all staff have minimum NVQ Level 2 and many are on NVQ (Level 3) training programmes. However staff, including the Registered Manager, have been informed by the Responsible Individual that Chadwin Road (81) DS0000058206.V269174.R01.S.doc Version 5.0 Page 15 there is no money available for training and that staff must finance their own training and would be reimbursed when their courses end. This expectation is unreasonable. There is a legal obligation under the Care Homes Regulations for all staff employed by the organisation to receive training appropriate to the work they perform. National Minimum Standards specify that the home must have a dedicated training budget. It must also have a designated person with responsibility for a training and development programme. Some information related to staff personnel files were missing for some staff members. Documentation related to all staff personnel records must be available for inspection. Chadwin Road (81) DS0000058206.V269174.R01.S.doc Version 5.0 Page 16 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, 40, 41, 42 Service users benefit from the positive leadership and management approach of the home. Service users views are taken into account in management planning. Service users’ best interests must be safeguarded by updated policies and procedures. EVIDENCE: The staff member interviewed informed that they had an open and positive relationship with the Registered Manager who offered them regular, ongoing support and supervision. The Registered Manager has demonstrated areas of strength and leadership, particularly in implementing new procedures to improving standards of service delivery. This includes the development of a performance standards checklist for staff to set standards and to ensure consistency of practise by staff, as examined at the previous inspection. This is used in supervision to identify strengths and weak areas and training needs identified. The Registered Manager has an active role in compiling care plan with service users and their key workers. Chadwin Road (81) DS0000058206.V269174.R01.S.doc Version 5.0 Page 17 She consults with service users regarding their needs and service received. For example, she has secured an appropriate day centre for service users and she has devised a service user questionnaire to gage their views about the homes’ decoration. Fire testing equipment are checked on a weekly basis and fire drills are being undertaken regularly. Gas, electrical wiring and Portable Appliance Test certificates were available. A water safety certificate was not available. There is a legal responsibility on small residential homes, as outlined in the approved code of practice by the Health and Safety Executive, to ensure that the risk from exposure to Legionella is properly controlled and that water systems are safe. A requirement to evidence that the home’s policies and procedures are reviewed and updated is restated. Chadwin Road (81) DS0000058206.V269174.R01.S.doc Version 5.0 Page 18 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 1 3 3 3 3 Standard No 22 23 Score 3 1 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 2 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 1 1 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 x 17 Standard No 31 32 33 34 35 36 Score 3 3 3 1 1 3 CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Chadwin Road (81) Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 1 1 x DS0000058206.V269174.R01.S.doc Version 5.0 Page 19 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 YA1 Regulation 4, 5 Requirement The Registered Manager must ensure that the Statement of Purpose accurately states the numbers of staff employed in the home. The Registered Manager must ensure that the Adult Protection Policy is revised to expand on the procedures followed by staff in the home. The Registered Manager must ensure that the bath panel is repaired or replaced. The Registered Manager must ensure that the drawer units in service users’ rooms requiring repair or replacement are attended to. The Responsible Individual and Registered Manager must ensure that records related to staff personnel information are available for inspection in the home. The Registered Manager must ensure that there is evidence that the homes’ policies and procedures are reviewed and DS0000058206.V269174.R01.S.doc Timescale for action 01/03/06 2. YA23 13(6) 01/03/06 3. 4. YA24 YA26 23 23(2) 01/03/06 01/03/06 5. YA34 17(2) 01/03/06 6. YA40 17 01/03/06 Chadwin Road (81) Version 5.0 Page 20 updated. Timescale of 10th Nov 05 not met. The Responsible Individual must ensure that a water safety certificate is available for inspection to evidence that the risk from exposure to Legionella is properly controlled and that water systems are safe. 7. YA42 13 (3)(4) 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. 1 Refer to Standard YA9 Good Practice Recommendations It is recommended that the format of the risk assessment forms is improved. 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