Inspection on 04/11/05 for Charlton Road

This inspection was carried out on 4th 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 no outstanding requirements from the previous inspection report, but made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Charlton Road 30/04/07

Charlton Road 05/05/06

Charlton Road 26/04/05

Charlton Road 01/10/04

Charlton Road 21/04/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Charlton Road 30a Charlton Road Blackheath London SE3 8TY Lead Inspector Ms Pauline Lambe Unannounced Inspection 4th November 2005 09:30 Charlton Road DS0000006756.V259374.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 Charlton Road DS0000006756.V259374.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. Charlton Road DS0000006756.V259374.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Charlton Road Address 30a Charlton Road Blackheath London SE3 8TY 020 8305 2425 020 8305 2425 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) Milbury Care Services Limited Mr Paul Augustine Doyle Care Home 5 Category(ies) of Learning disability (4), Learning disability over registration, with number 65 years of age (1) of places Charlton Road DS0000006756.V259374.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1 place registered for LD(E) in respect of named service user only. Date of last inspection 26th April 2005 Brief Description of the Service: 30a Charlton Road is a registered care home providing accommodation and nursing care for four adults with a learning disability. It is situated near to “Blackheath Standard” and a local shopping centre that has good public transport links. The home is one of a group of six homes for adults with learning disabilities situated in the London Borough of Greenwich and managed by Milbury Community Services Ltd. The property is a detached bungalow which provides four single bedrooms, a lounge / dining room, kitchen, laundry room, toilet and bathing facilities. The property had small gardens to the front and rear. The home has links with the Greenwich Community Learning Disabilities Team (C.L.D.T) to provide a multidisciplinary service. Members of the C L D T are involved in placements in the home, monitoring resident care and progress and provide day care services and links to specialist health care. Charlton Road DS0000006756.V259374.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was done on 4th November 2005 over 6 hours. The service was last inspected on the 26th April 2005. The manager not on duty and inspection was done with the help of the nurse in charge. Two residents were in the home at the time and the others were out at day centres. The inspection included a tour of the premises, inspecting records, talking to residents and members of staff team. As no relatives were seen comment cards were left in the home for them to complete and return to the Commission if they wished. What the service does well: What has improved since the last inspection? What they could do better: Management must ensure new residents are admitted only following an assessment of need and confirmation that the home can meet those needs. The provision of activities and holidays must be reviewed to ensure these adequately meet the needs of the residents. The one bathroom provided must be maintained in working order and available to residents. The kitchen area and lounge carpet must be kept clean. Management must check fire doors regularly and ensure these operate correctly and do not pose a risk to residents. The garden must be kept tidy and provide a pleasant space for resident use. Recruitment procedures must include checking nurses employed are registered with the Nursing & Midwifery Council. Staff must have access to a clear policy and procedure as to evacuation of the home in the event of a fire. Charlton Road DS0000006756.V259374.R01.S.doc Version 5.0 Page 6 Management must have system in place to review and improve the quality of the service. Outcomes of such a review must be made available to the residents, relatives, the Commission and other stakeholders. 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. Charlton Road DS0000006756.V259374.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 Charlton Road DS0000006756.V259374.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): 3 and 5. The registered person must ensure they comply with regulation when admitting a new resident. Up to date contracts for service were seen in the files viewed. EVIDENCE: One new resident had been admitted since the last inspection. The resident was moved from a sister home and no pre-admission assessment had been completed. From the evidence provided the move was not managed well. It would seem the resident left the other home to go the day centre and returned to this home at the end of the day. The residents had not had any introductory visits did not have the opportunity to meet the other residents or staff. Up to date contracts for service were seen in resident’s files and showed the fees paid and who was responsible for paying this. Requirement 1. Charlton Road DS0000006756.V259374.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. Individual care plans were prepared and included risk assessments. Efforts must be made to ensure these are kept under review. EVIDENCE: Two care plans were inspected. One was well written and included risk assessments, relevant care plans to show how the resident’s needs were to be met and review dates. The second care plan was similar but had not been reviewed on the dates planned. Recommendation 1. Charlton Road DS0000006756.V259374.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): 12 and 17. Management must ensure residents have more opportunity to enjoy social and leisure activities, including the quality of the annual holiday. Resident’s nutritional needs were being met. EVIDENCE: Social care plans were prepared for residents. One resident indicated how they spent their day and seemed to be in control of this. A monthly record of activities was kept for each service user. These records showed that residents had participated in very little social and leisure activities for the month of October 2005. Staff indicated that there had been a decrease in social activity and the annual holidays for residents. The residents had only a weekend away as their annual holiday this year. The home had use of a mini-bus and again staff said that this does not get used as much as it used to. The vehicle was safely maintained and insured. The kitchen was kept clean by the staff. A cleaning schedule was in place. Although the kitchen was generally clean more attention was needed to Charlton Road DS0000006756.V259374.R01.S.doc Version 5.0 Page 11 cleaning the inside of the doors and the inside of the units. Kitchen equipment was clean and in working order. Adequate supplies of fresh, frozen and dry foods were seen. Records were kept for fridge, freezer and food temperatures. Residents were supported to join in with menu planning. Staff used pictures to help them to do this. The menus included resident choice and showed that a varied diet was provided. Only two residents were able to eat the other two were artificially fed and their dietary needs assessed by a dietician. Equipment for artificial feeding was properly cleaned and stored. Requirements 2 and 3. Charlton Road DS0000006756.V259374.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): 19 and 20. Resident’s healthcare needs were adequately met and medicines were safely managed. EVIDENCE: All residents were registered with a G.P and it was evident they were supported to access other health care such as dental, optical, dietician and chiropody. Specialist health care was accessed through G.P referral. Accident records were kept but did not always include full details. Staff must ensure they fill in all the information required and indicate whether the accident was witnessed or not. One resident had a high number of falls and the manager had implemented a procedure with the agreement of relatives as to how this should be managed. Medicines were generally well managed. Because there were concerns with drug errors in the past the manager had introduced a system to check medicines weekly. Records were not kept for medicines returned to the pharmacist. Requirement 4 and recommendation 2 Charlton Road DS0000006756.V259374.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): None. EVIDENCE: These standards were assessed as met at last inspection. No complaints were made to the home or the Commission since the last inspection. Charlton Road DS0000006756.V259374.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): 24,25,26,27,29 and 30. The environment was suitable to meet the needs of the residents. The home was clean and tidy. The only bath in the home was out of order for some time and must be repaired or replaced for the comfort of the residents. EVIDENCE: Residents’ bedrooms were clean, tidy and decorated and fitted to suit the residents. Each room had a ceiling hoist and these were last inspected on 6/7/05. Rooms were nicely personalised and resident’s personal clothing was neatly stored and in good condition. The doors to two bedrooms did not close properly and in the event of a fire would pose a risk to the occupants. An immediate requirement was left for the registered person to have these doors repaired. At the time of writing this report the home had confirmed in writing to the Commission that they had met the immediate requirement. The lounge was bright and tidy. Pottery items made by the residents at the day centres were displayed. The room was generally clean but the carpet needed cleaning. Since the last inspection some new furniture had been provided. This included a dining suite and a more suitable chair for one resident. The staff were of the opinion that the dining chairs were not suitable for the residents. The chairs were quite narrow and had no arm supports. Charlton Road DS0000006756.V259374.R01.S.doc Version 5.0 Page 15 The home had one bathroom and one shower room. The shower room was clean and tidy and had hand-washing facilities provided. The bathroom was a bit cluttered and the bath had been out of order since 6/7/05. Staff said that currently the room was not being used and added that residents missed not having a bath. On their days off residents had a lie in, breakfast in bed if they choose and then used to have a relaxing bath. Bedrooms and communal space were adequately clean and tidy. The garden was quite overgrown, unkempt and in need of attention. Requirements 5,6,7 and 8. Charlton Road DS0000006756.V259374.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 and 34. The home maintained adequate staffing levels. EVIDENCE: From the rotas inspected adequate staffing levels were maintained. At the time of this inspection one resident needed one to one care at certain times of the day. This was being provided and funded by social services. Standard 34 could not be assessed, as the manager was not in the home. A requirement made at the last inspection will be reviewed at the next inspection. Requirement 9. Charlton Road DS0000006756.V259374.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): 39 and 42. From the evidence available attention was given to ensuring the safety of residents and others. EVIDENCE: One requirement made at the last inspection in relation to standard 39 was not reviewed as the manager was not in the home and staff did not have the relevant information. This will be reviewed at the next inspection and in the meantime the registered person should send a copy of the quality assurance review outcome to the Commission. A selection of safety records were viewed. These showed that hoists were serviced on 6/7/05, fire safety equipment was serviced on 3/11/05 and other systems and equipment had been appropriately maintained. There was no evidence to show that one requirement made in relation to standard 42 had been met. Requirements 10 and 11. Charlton Road DS0000006756.V259374.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 x x 2 x 3 Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 2 4 2 2 3 2 LIFESTYLES Standard No Score 11 X 12 2 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 X 2 X X CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Charlton Road Score X 2 2 x Standard No 37 38 39 40 41 42 43 Score X X 2 X X 2 X DS0000006756.V259374.R01.S.doc Version 5.0 Page 19 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 YA3 Regulation 14 Requirement The Registered Person must not admit a resident to the home unless they have access to or have completed an assessment of need and have confirmed in writing to the resident that based on the assessment the home can meet their needs. The Registered Person must consult residents about the programme of activities arranged and ensure this meets their needs and interests. The Registered Person must ensure the home is kept clean. Attention must be given to keeping the inside of the kitchen units clean and hygienic. The Registered Person must ensure records re kept for all medicines returned to the pharmacist. The Registered Person must ensure all fire doors in the home close properly to ensure the safety of the occupant in the event of a fire. An Immediate requirement was left for the registered person to DS0000006756.V259374.R01.S.doc Timescale for action 23/12/05 2 YA12 16 23/12/05 3 YA17 23 23/12/05 4 YA20 13 16/12/05 5 YA25 23 07/11/05 Charlton Road Version 5.0 Page 20 6 YA27 23 7 YA28 23 8 YA30 23 9 YA34 19 10 YA39 24 11 YA42 13 repair two bedroom doors that did not close fully. The Registered Person must ensure all bathing facilities are maintained in good working order and available to residents. The one assisted bath provided must be repaired or replaced. The Registered Person must ensure the premises are maintained internally and externally. The garden must be kept tidy and provide a pleasant area for residents to use. The Registered Person must ensure the home is kept clean. The lounge carpet must be kept clean. The Registered Person must ensure recruitment procedures comply with regulation and includes checking that nurses employed are registered with the Nursing & Midwifery Council. (This requirement was not reviewed and the compliance date remains unchanged) The Registered Person must Ensure a system is in place to Review and improve the quality of care provided in the home. Outcomes of the quality assurance reviews must be made available to residents, relatives, the Commission and others. (This requirement was not reviewed and the compliance date remains unchanged) The Registered Person must ensure the home has a clear policy and guidance in relation to evacuation in the event of a fire. (There was no evidence to show compliance date of 30/06/05 had been met) 16/12/05 23/12/05 16/12/05 31/05/05 30/06/05 16/12/05 Charlton Road DS0000006756.V259374.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 2 Refer to Standard YA6 YA19 Good Practice Recommendations The registered Person should ensure residents care plans are kept under review. The Registered Person should ensure staff fill in all details on accident records and indicate whether the acceded was witnessed or not. Charlton Road DS0000006756.V259374.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 Charlton Road DS0000006756.V259374.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. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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