Inspection on 01/08/05 for Colegrave Road, 77- 79

This inspection was carried out on 1st August 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 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Colegrave Road, 77- 79 12/06/07

Colegrave Road, 77- 79 23/06/06

Colegrave Road, 77- 79 30/12/05

Colegrave Road, 77- 79 06/01/05

Colegrave Road, 77- 79 16/08/04

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

CARE HOME ADULTS 18-65 79 Colegrave Road 79 Colegrave Road Stratford London E15 1DZ Lead Inspector Helen Fontaine Unannounced Inspection 1 August 2005 at 10:00am st 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 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 Stationary 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. 79 Colegrave Road G57 G06 S58207 79 Colegrave Road V242226 010805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 79 Colegrave Road Address 79 Colegrave Road, Stratford, London, E15 1DZ Telephone number Fax number Email 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 8534 1153 Consensa Care Limited Post Vacant Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places 79 Colegrave Road G57 G06 S58207 79 Colegrave Road V242226 010805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 6th January 2005 Brief Description of the Service: 79 Colegrave Road provides accommodation and care for up to three people with mental health support needs. The home’s statement of purpose emphasises helping the individual service users to move onto more independent living through the development of life skills, confidence building and psychological stability. The home is owned by the Consensa Care Limited that also owns 77 Colegrave Road. Both homes are managed by the same Acting Manager as the previous Registered Manager has left and the service users often mix and spend time together. The company that also owns other residential care homes in the area, plans to merge two homes in Colegrave Road into one in the near future. The property is a Victorian conversion and blends well with neighbouring houses. It is situated in a quiet residential street near Stratford Station and is well served by public transport and other local facilities. Parking is unrestricted in the area. 79 Colegrave Road G57 G06 S58207 79 Colegrave Road V242226 010805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over 3 hours and was carried out because there were a number of requirements from the previous inspection. One other unannounced visit has been made since the last announced inspection. Letters sent to the registered person following those visits can be obtained from the Commission for Social Care Inspection office on request. The inspector looked around some parts of the building and a number of records were inspected. Both residents and one member of staff were spoken to. What the service does well: What has improved since the last inspection? What they could do better: Over the past year the home has not been managed in ways that ensure that the people living there are safe and well cared for. There is a new manager who has been in post for three months, the manager must make sure that the serious concerns set out below are put right. The Acting Manager does need to be Registered with the Commission for Social Care Inspection. The fire door in the kitchen must be repaired and must not be left propped open by a chair, currently the fire door cannot be closed at all. The door to the bathroom needs to be repaired, so that it can be closed and locked without having to lift it into place. The home (including the basement) is as far as particle free from hazards and that the risk assessment process is recorded. 79 Colegrave Road G57 G06 S58207 79 Colegrave Road V242226 010805 Stage 4.doc Version 1.40 Page 6 Whilst there has been some redecoration there needs to be as a matter of urgency, some extensive cleaning and re-decoration. The empty room does need to be completely renovated, before another Service User moves in. 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. 79 Colegrave Road G57 G06 S58207 79 Colegrave Road V242226 010805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection 79 Colegrave Road G57 G06 S58207 79 Colegrave Road V242226 010805 Stage 4.doc Version 1.40 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 standard(s) 2 The Home’s admission procedure was under review. EVIDENCE: The existing admission procedure was produced, the Manager said that a new one is currently held at head office. The Manager has not seen this yet, but it would be used for any further residents moving in. The Manager said that they felt that the existing assessment form is too long and just made too much paper work. Individual records are kept for each of the two residents and inspection of the records of showed assessments, care plans and reviews. One of the residents has a booked Care Programme Approach review, which is a multi disciplinary review of the Service Users needs. 79 Colegrave Road G57 G06 S58207 79 Colegrave Road V242226 010805 Stage 4.doc Version 1.40 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 standard(s) 7 and 9 Residents are encouraged to make some decisions about their lives, however these are restricted. EVIDENCE: One Service User spoken to said that they are very keen to move to their own flat and during a discussion about their medication said, “If I live in a flat of my own it would be dangerous to stop taking medication that I have been on for so long”. This showed a clear understanding of decisions about their life and the risks. The other resident spoken to was also keen to move to independent living. The door to the home and the home next door are kept locked and neither of the Service Users have keys, this does not allow Service Users the choice to come and go as they please. There was one incident documented and seen during the inspection, where one of the Service Users wished to go out and called the police as the door was locked. The Manager said that the residents now help the staff with the cleaning and are responsible for cleaning their rooms. Both residents spoken to said that they now do this, one of the residents clearly expressed a positive view on being involved. However the general poor condition of the home, does not 79 Colegrave Road G57 G06 S58207 79 Colegrave Road V242226 010805 Stage 4.doc Version 1.40 Page 10 encourage the two residents to see much improvement when they have undertaken some cleaning. One of the residents spoken to said that they now cook their own meals, the Manager confirmed this and said “that one of the staff that is good at cooking the sort of meals this resident liked, helped them to cook”. However there is some concern about the lack of risk assessments for this, there need to be robust risk assessments in place for all these activities. 79 Colegrave Road G57 G06 S58207 79 Colegrave Road V242226 010805 Stage 4.doc Version 1.40 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 standard(s) 12,13,15,16 and 17 There needs to be more work done in working with service users accessing the community when ever they wish to. More choices for service users are necessary - including choices over menu. EVIDENCE: During the inspection documents reviewed showed that one of the residents who had lived for many years outside of the area, now had contact with their family. It was documented that this service user now went and stayed with their family. The other resident spoken to said that they did not have any contact with family or friends. One of the residents spoken to said that they now attend a therapeutic centre and said that they “liked it and hoped they would get a job there”. The Manager had a plan of the weekly activities that included swimming, shopping and having meals out. However there was no evidence either from the documentation of from discussions with the residents, that they are involved in local community events. The issue over the locked front door of both homes, needs to be addressed to allow Service Users access the community when they choose to. 79 Colegrave Road G57 G06 S58207 79 Colegrave Road V242226 010805 Stage 4.doc Version 1.40 Page 12 One resident spoken to said “I am able to manage my own finances”, the Manager said that the residents are now encouraged to look after their own rooms. It was noticed that one of the residents did not have access to their own cigarettes, these were kept locked in the office. There needs to be an agreement with this resident that they understand to demonstrate that they are content with this arrangement. The residents are now cooking their own meals with assistance, both residents spoken to said that they were happy with this. However one resident said “they did not have a lot of choice”, but did point out that they were overweight and had to be careful what they ate. During the inspection both the fridge and the freezer were inspected, there did not appear to be much variety in foods stocked. 79 Colegrave Road G57 G06 S58207 79 Colegrave Road V242226 010805 Stage 4.doc Version 1.40 Page 13 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 standard(s) 20 Service Users are not encouraged to self medicate and this should be further explored with the appropriate review and risk assessment. The whole issue of medication needs some attention so that records are kept appropriately. EVIDENCE: Medication is kept locked in the other residential home, there is no medication held in the residents own home. The Manager said that one of the residents comes over to take medication, observed and supported by staff. Both residents said that their medication made them drowsy and one of the service user spoken to said “they have increased my medication, but I do not know why”. The other spoken to said “The staff want me to get up, but my medication makes me so sleepy that I cannot wake up”. The medication documentation was done with both residential homes together, there was no clear receipt of disposal of medication and no evidence of self medication or choice being offered. It was noted that sheets of paper with the weight charts made up, were also kept in the medicating sheet folder. 79 Colegrave Road G57 G06 S58207 79 Colegrave Road V242226 010805 Stage 4.doc Version 1.40 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 standard(s) 22 and 23 Complaints are not handled properly to provide residents with confidence that their concerns will be listened to, taken seriously and acted upon. EVIDENCE: The “Unusual Occurrences” book had a recent entry and the Complaints book had no entry. One Service User spoken to said that, “most staff are kind but some treat them differently”. This resident also said that she is nervous when they are on duty and that she is now not allowed to have access to her money. The Manager said that she felt that they Key Worker sessions allowed Service Users the opportunity to have their concerns listened to, however there was no evidence that they were acted upon. There was a robust Adult Protection Policy and procedure and the Manager was clearly aware when asked about the Local Authority Adult Protection Policy and Procedure. 79 Colegrave Road G57 G06 S58207 79 Colegrave Road V242226 010805 Stage 4.doc Version 1.40 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 standard(s) 24 and 30 Little or no improvements to the décor have been made. There are a number of serious matters outstanding which put people at risk of serious harm and do not provide safe and comfortable surroundings in which to live. EVIDENCE: The Manager said that some of the walls in the lounge had been painted, but that kickboards would not be done until all the walls were done. A number of areas require attention, in particular: • The wallpaper, woodwork and kickboards were dirty and stained. This creates a poor first impression of the home. • Carpets on the landings, stairs and rooms were dirty, stained and worn. This not only looks unsightly but will become a trip hazard in the near future. This carpeting must be repaired or replaced to ensure safety. • The bedroom inspected was in an uninhabitable state and was stained from nicotine, which also had an unpleasant odour. • The intumescent strip remained missing from the bathroom door thus making that door non-compliant with the fire-safety regulations. • The door handle to the fire door in the kitchen was broken and came off when the Manager tried to use it. The door had to held open by a chair and breached fire-safety regulations. 79 Colegrave Road G57 G06 S58207 79 Colegrave Road V242226 010805 Stage 4.doc Version 1.40 Page 16 • • The basement remains a hazard and should as far as practicable be free from hazards and a risk assessment should be recorded. The whole house smelled of nicotine, which was unpleasant and means of addressing this should be investigated. 79 Colegrave Road G57 G06 S58207 79 Colegrave Road V242226 010805 Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34 and 35 The procedures for the recruitment of staff are not robust and do not offer protection to people living in the home. EVIDENCE: Documented staff meetings were seen and it was noted that some staff still do not have current CRB checks. The Manager said that everyone is in the process of getting documentation for their CRB’s and commented that future staff would not be employed without a CRB. A staff file seen had a current CRB disclosure in place. A member of staff spoken to said “the training is good”. The member of staff said there are difficulties with the rotas, but someone from the company is coming to discuss this with them. The member of staff felt the home was good and had no concerns. 79 Colegrave Road G57 G06 S58207 79 Colegrave Road V242226 010805 Stage 4.doc Version 1.40 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) No assessment was made of these Standards at this inspection. EVIDENCE: No assessment was made of these Standards at this inspection. 79 Colegrave Road G57 G06 S58207 79 Colegrave Road V242226 010805 Stage 4.doc Version 1.40 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 1 x x x Standard No 22 23 ENVIRONMENT Score 1 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x 1 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 x x x x x 1 Standard No 11 12 13 14 15 16 17 x 2 1 x 1 2 2 Standard No 31 32 33 34 35 36 Score x x x 1 1 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 79 Colegrave Road Score x x 1 x Standard No 37 38 39 40 41 42 43 Score x x x x x x x G57 G06 S58207 79 Colegrave Road V242226 010805 Stage 4.doc Version 1.40 Page 20 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 7 Regulation 13(4) Requirement The Registered person must ensure that service users are enabled to access community activities and this must be documented on their care plans. The Registered person must ensure that service users have freedom to access the community with clear risk assessments where this is restricted. The Registered person must ensure that service users are provided with opportunities to maintain contact with friends and family. The Registered person must provide adequate food which is varied and meets the expressed needs of service users. The Registered person must make arrangements for the safe administration of medication. The Registered person must ensure that service users are effectively consulted and action taken to respond to consultation must be evidenced. The Registered person must ensure that a homely, comfortable and safe Timescale for action 1/09/05 2. YA13 13(7) 1/09/05 3. YA15 16(2) 1/09/05 4. YA17 16(2) 1/09/05 5. 6. YA20 YA22 13(2) 12(3) 1/09/05 1/10/05 7. YA24 13(4) 1/10/05 79 Colegrave Road G57 G06 S58207 79 Colegrave Road V242226 010805 Stage 4.doc Version 1.40 Page 21 8. YA30 23(2) 9. YA34 19(1) 10. YA35 18(1) environment is maintained for service users. The Registered person shall maintain all parts of the care home in a clean and reasonably decorated condition. The Registered person shall not employ a person to work in the home unless they are in receipt of a satisfactory CRB disclosure. The Registered person shall ensure that all staff are suitably trained to meet the needs of service users. 1/10/05 1/09/05 1/11/05 11. 12. 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. 3. 4. Refer to Standard YA9 YA12 YA16 Good Practice Recommendations Service Users are enabled to take responsible risks within the context of the Care Plan and Risk Assessment. Service Users are encouraged to take part in valued and fulfilling activities. Daily routines and house rules promoted , individual choice and freedom of movement. 79 Colegrave Road G57 G06 S58207 79 Colegrave Road V242226 010805 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection Gredley House 1-11 Broadway London E15 4BQ 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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