Inspection on 09/12/05 for Cheam Road (101)

This inspection was carried out on 9th December 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cheam Road (101) 03/05/07

Cheam Road (101) 05/09/05

Cheam Road (101) 28/02/05

Cheam Road (101) 22/07/04

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

CARE HOME ADULTS 18-65 Cheam Road (101) 101 Cheam Road Sutton Surrey SM1 2BE Lead Inspector David Pennells Unannounced Inspection 9th December 2005 18:30 Cheam Road (101) DS0000007154.V272391.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 Cheam Road (101) DS0000007154.V272391.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. Cheam Road (101) DS0000007154.V272391.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Cheam Road (101) Address 101 Cheam Road Sutton Surrey SM1 2BE 020 8642 0307 020 8642 1134 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) www.caremanagementgroup.com Care Management Group Limited Care Home 6 Category(ies) of Learning disability (0) registration, with number of places Cheam Road (101) DS0000007154.V272391.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents with challenging behaviour Date of last inspection 5th September 2005 Brief Description of the Service: 101 Cheam Road is maintained, managed and staffed by the Care Management Group (CMG). The home, opened in 1996, is registered with the Commission to provide residential care for up to six women with learning disabilities and challenging behaviours. The house is a large detached Victorian property situated in a residential area to the west of Sutton town centre, within a half-mile’s walk of the home. A wide variety of shops, cafes and restaurants and other opportunities are available there, as are excellent transport links. Busses stop close by outside the house. Cheam Village is also not far too away (a bus or strenuous walk), in the opposite (westerly) direction - again offering many community resources. Accommodation in the home comprises: six single bedrooms, an open plan kitchen and dining area, and a separate lounge with a conservatory (for smoking) attached. There is also a small laundry cupboard and an office. There are sufficient bathroom / shower and toilet facilities throughout the home to meet all service users’ needs. The large garden at the rear is well maintained and there is a patio with garden furniture for service users’ use. Cheam Road (101) DS0000007154.V272391.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection visit found the service users and staff tucking into substantial platefuls of their ‘Friday Night Chinese Takeaway’. Service users greeted the inspector and he left the feast to check documentation in the office area whilst both staff and service users carried on with their meal. The inspector was offered refreshment – for which he was very grateful – and he thanks both service users and staff for their welcome, cooperation and hospitality throughout the inspection visit – which terminated soon after 9.00pm. The inspector was pleased to observe the efficient and friendly running of the house in this ‘out-of-hours’ visit – and was pleased to notice good practice continuing throughout this time. What the service does well: What has improved since the last inspection? Attention has now been paid to risk assessment updating and reviews thereof, and the issues raised concerning hazardous chemicals – this leaving just one of three requirements outstanding (see section below). The home’s Statement of Purpose now has details of all staff members’ qualifications and training expertise, and staff members are attempting to facilitate greater participation in decision making by service users at the home. The home continues to run within well-managed routines and processes, which promote a positive and generally safe outcome. Cheam Road (101) DS0000007154.V272391.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. Cheam Road (101) DS0000007154.V272391.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 Cheam Road (101) DS0000007154.V272391.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): None inspected at this visit. Prospective service users can be confident that they will have the opportunity to find out about the home, to visit (including staying for short periods) and be assured that the home can meet their needs prior to making a firm decision to stay. EVIDENCE: The above judgement statement was made in regard to the last inspection visit, when standards 1 – 4 were inspected and all found to be satisfactorily ‘met’. Cheam Road (101) DS0000007154.V272391.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): 9 & 10. The home maintains care plans and assessment documents designed to ensure that the needs of service users are met in a focused and individual way. Service users can be assured that their rights to individuality and selfexpression are protected; consultation and sharing of information will involve and take into account the wishes and aspirations of the service user. Service users can generally be assured that risk-taking will be an integral part of the support / protection plans put in place by the home. Service users can be assured that their personal information is kept in line with the appropriate CMG company policies and statutory Data Protection requirements. EVIDENCE: The first three judgement statements above were made at the last visit, when the third paragraph expressed some concerns about keeping risk assessments up-to-date and risk assessments being put in place immediately a service user moves in. Cheam Road (101) DS0000007154.V272391.R01.S.doc Version 5.0 Page 10 Due to the stability of the service user group at Cheam Road, no new service users have entered the house, but the risk assessments seen were all in currency thanks to regular reviews. The requirement is therefore no longer applicable and all key standards in this section are now, therefore, found ‘met’. The Data Protection Standard 10 was considered at this inspection. The home has a corporate written Confidentiality Policy. Service users previously spoken to have informed the inspector that they were aware that they could access personal information held about them by the home, if they so wished, though did not express any current interest or see any necessity in doing so. The home’s files for service users are kept in the main office that was locked when the inspector called at the house; management are clearly happy that this is sufficiently secure. The registered provider is duly notified / registered with the Information Commissioner under the Data Protection Act 1998, thus ensuring – with the provider undertaking to ensure - adherence to good practice in general. Cheam Road (101) DS0000007154.V272391.R01.S.doc Version 5.0 Page 11 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): None directly inspected at this visit. Service users can be assured that the service provides opportunities for them to engage in activities both within and outside the home, and to adopt a lifestyle suited to the individual. Relatives / friends can expect a positive welcome from the home, within the context of respect for a service user’s own choice and decision-making. Service users can expect to be provided with a good standard of nutritious and wholesome food – meeting dietary needs and ensuring that mealtimes are a pleasant and enjoyable time. EVIDENCE: All standards in this section were inspected at the last inspection visit and found ‘met’. Nothing at this visit has suggested to the inspector that the situation has changed – so the above judgement statements are reiterated from the last report. Cheam Road (101) DS0000007154.V272391.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): 20. Service users can be assured that their personal, health care and emotional needs will be recognised and met by the home’s assessment and care planning programme. The systems adopted by the home regarding medication ensure the safety and consistent treatment and support for each service user. EVIDENCE: The three key standards were all found ‘met’ at the last inspection – reflected by the reiterated judgement statements above. The inspector did check the medication records and the storage of medication to ensure that all storage and recoding was up-to-date and consistent. This was indeed the case at the time of the inspection visit – and the above judgement statements – taken from the last inspection report reiterate the evident ongoing situation at this visit. Cheam Road (101) DS0000007154.V272391.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): 23. Service users can be confident that their comments and complaints are responded to, with appropriate action taken. The home provides adequate direct support to service users to ensure that they are protected from harm and any form of abuse - however the home’s policy and procedure relating to investigating allegations of abuse and dealing with vulnerable adults does not blend in with the local authority procedure adequately – thus putting service users at risk through the staff possibly mishandling such situations. EVIDENCE: The first judgement paragraph covers the last inspection’s assessment concerning complaints – which was satisfactorily met. The second standard’s review last inspection contained a recommendation requesting that the registered provider take urgent steps to ‘tie in’ the CMG Adult Abuse policy with that of the host local authority (London Borough of Sutton – a newly revised procedure has been issues in 2005). This has not been done, and the inspector is concerned that the two policies do not concur. The ‘current’ CMG policy (April 2002) does not cover immediately reporting the issue directly to the local social services care management team – a protocol that is now established with all care providers within the Borough (and common to other Boroughs too). Although the staff members have attended training on Vulnerable Adults issues, the possibility of confusion and therefore potential delay of correct reporting and seeking advice puts service users at potential risk from mis-management of such a situation. Cheam Road (101) DS0000007154.V272391.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): 29. Service users can expect to live in a clean, warm and comfortable environment designed to meet their individual needs and providing adequate services and domestic facilities. Service users can be assured that, once the steps to cover exposed radiator surfaces in high-risk areas are undertaken, the home will be a safe environment in which to live their lives without unnecessary risk. EVIDENCE: All standards - except 29 - were found ‘met’ at the last inspection visit. The house continues to present at a very high standard. The home is conveniently located in West Sutton, in a pleasant residential area. The location is ideal to enable access to many community resources, using local transport (busses stop close by). The home is ‘ordinary’ in external appearance, in keeping with the local ambience; service users can feel as if they are living ‘at home’. The house is well maintained and kept clean and tidy. Furnishings are of good quality, and care is taken with the décor throughout. The communal space is more than adequate for the six service users and the staff who provide the service alongside them. There is clearly a corporate sense of ‘pride’ in the house and the living environment’s standards. Cheam Road (101) DS0000007154.V272391.R01.S.doc Version 5.0 Page 15 Maintenance and servicing of equipment at the home was up to date and certificates were available to evidence all such provision. Regular in-house checks (fire system, etc.) are undertaken by staff members and these records, amongst many others, are regularly checked during the Regulation 26 visits of the person-in-control of the home. One requirement relating to Standard 29 - the need to ensure that radiator surfaces in areas where there could be significant skin exposure (such as bath / shower rooms and toilets) are covered - was in part met, as the builders were evidenced to have attended the house on 22/11/05 to measure up the radiators to build and supply them. The requirement is reiterated in this report, as the covers have not yet been installed – and this is an essential health & safety element to be addressed. Cheam Road (101) DS0000007154.V272391.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): None inspected at this inspection. Service users can be assured that they will be supported at all times by staff who are experienced and competent in their work, being provided in sufficient numbers to meet their identified needs. Service users can expect to be provided a service that ensures their safety and protection from abuse – through thorough recruitment processes and ongoing staff support arrangements. EVIDENCE: Standards 31 – 35 (thus incorporating the required key standards) were inspected at the last inspection visit and all found to be met. In the absence of the registered manager on this occasion the inspector chose not to explore these standards. Cheam Road (101) DS0000007154.V272391.R01.S.doc Version 5.0 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 & 42. The home operates a set of management systems that ensures that service users benefit from a well-run and well-lead organisation. Service users can be assured that generally their rights and interests are well served and protected through the home’s approach to record keeping, policies & procedures and the day-to-day conduct of the home. Service users can be assured that their welfare, health and safety is safeguarded through the home’s rigorous adherence to appropriate guidance and regulations concerning best safety practice. EVIDENCE: The above set of judgement statements is brought forward to this inspection report from the previous, reflecting the generally good level of management input to the home. Margaret Mohamed has been in place as Acting Manager for the last fifteen months – and it is noted that the Commission has not received a formal application for her registration as manager. It is hoped that the registered provider will rectify this omission as soon as is practicable. Cheam Road (101) DS0000007154.V272391.R01.S.doc Version 5.0 Page 18 The one requirement outstanding from the last inspection report was with regard to the home having an excess of cleaning materials that were openly available within the home rather than being stored in line with hazardous chemicals safety Regulations. A service user was also inappropriately storing certain cleaning materials in their room. The home has now addressed this issue by reducing the levels of stocks held ensuring that there is no ‘overflow’ to deal with. Cheam Road (101) DS0000007154.V272391.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 X X X X Standard No 22 23 Score X 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X 1 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X X X X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Cheam Road (101) Score X X 3 X Standard No 37 38 39 40 41 42 43 Score 2 X X X X 3 X DS0000007154.V272391.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? YES 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 YA23 Regulation 13(4) Requirement A previous recommendation now a requirement: The provider’s policy with regard to adult abuse must be amended to accurately tie in the approach required under the multi-agency LB Sutton 2005 Vulnerable Adults Procedure Guidelines. The current (revised April ’02) policy is not explicit enough about the agreed procedural routes for reporting an abuse issue. Protective covers must be provided for radiators located in bathrooms and toilets throughout the house – and in other locations where there is a risk of exposure to hot surfaces. Timescale of 15/11/05 not met – the builders had been to the home and ‘measured up’ for their installation. Risk assessments were in place in the interim.) The registered provider must propose a candidate for registration as manager to the home. Timescale for action 31/01/06 2. YA29 13(4) 31/01/06 3. YA37 8&9 31/01/06 Cheam Road (101) DS0000007154.V272391.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. Refer to Standard Good Practice Recommendations Cheam Road (101) DS0000007154.V272391.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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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