Inspection on 18/09/05 for Companion in Care

This inspection was carried out on 18th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Companion in Care 25/09/06

Companion in Care 19/04/05

Companion in Care 10/12/04

Companion in Care 29/06/04

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 Companion In Care 24 Borthwick Road Leyton London E15 1UD Lead Inspector Rob Cole Unannounced Inspection 18 September 2005 at 10:00am th 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. Companion In Care G56 G06 S43228 Companion In Care V246004 180905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Companion In care Address 24 Borthwick Road, Leyton, London, E15 1UD 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 8519 4135 020 8809 7044 Companion In Care Ltd Mrs Kehinde Ollifunso Ajumobi Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places Companion In Care G56 G06 S43228 Companion In Care V246004 180905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 19th April 2005 Brief Description of the Service: Borthwick Road is a three bedroomed house registered to provide care to adults of either gender with a mental disorder. The home was first registered in February 2004. The home is situated in a residential area of Leyton, in the London Borough of Waltham Forest, and is close to shops and other local amenities and transport networks. The home is indistinguishable from other homes in the area. The home is privately run. Companion In Care G56 G06 S43228 Companion In Care V246004 180905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 18/9/05 and was unannounced. The inspector had the opportunity of speaking with service users and staff from the home. Overall the inspector considers this to be a well run home, and that service users receive appropriate care and support. Service users spoken to informed the inspector that they are happy with the level of care provided. There are some issues that must be addressed, and these are highlighted within the report. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Companion In Care G56 G06 S43228 Companion In Care V246004 180905 Stage 4.doc Version 1.40 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Companion In Care G56 G06 S43228 Companion In Care V246004 180905 Stage 4.doc Version 1.40 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4 anb 5 The inspector was satisfied that service users are given sufficient information about the home to enable them to make an informed choice as to move in or not. This information is provided through trial visits and written documentation. EVIDENCE: The home has a Statement of Purpose and Service User Guide in place. Both documents are written in plain English, and are dated with a review date indicated. The CSCI logo has been removed from these and other documents since the last inspection. The Statement includes details of the aims and objectives, facilities and services provided and management arrangements for the home. The Guide contains the homes complaints procedure and key contract details. However, the Guide is not fully in line with National Minimum Standards (NMS), for instance it does not include details of the homes physical environment or of the staff team’s experience and qualifications. This must be addressed. All service users have a written contract/statement of terms and conditions in place. These have been signed by the homes manager and the service user. However, not all contracts are in line with NMS, for example the contract for the most recent service user to be admitted to the home does not include the cost of services provided, nor does it state what services are not covered by the fees payable. It is a repeat requirement that all service users have contracts in line with NMS. Companion In Care G56 G06 S43228 Companion In Care V246004 180905 Stage 4.doc Version 1.40 Page 8 The home has an admissions procedure, this states that service users will be given the opportunity of visiting the home prior to making a decision as to move in or not. Service users spoken to confirmed to the inspector that they were given this opportunity. At a previous inspection it was found that a service user had been admitted to the home without a thorough pre admission assessment been carried out. As there have been no further admissions to the home since that inspection, the requirement that the home carries out pre admission assessments is repeated in this report. Companion In Care G56 G06 S43228 Companion In Care V246004 180905 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) None The standards in this section were not tested as part of this inspection, but will be tested as part of the next inspection. EVIDENCE: The standards in this section were not tested as part of this inspection, but will be tested as part of the next inspection. Companion In Care G56 G06 S43228 Companion In Care V246004 180905 Stage 4.doc Version 1.40 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 standard(s) None The standards in this section were not tested as part of this inspection, but will be tested as part of the next inspection. EVIDENCE: The standards in this section were not tested as part of this inspection, but will be tested as part of the next inspection. Companion In Care G56 G06 S43228 Companion In Care V246004 180905 Stage 4.doc Version 1.40 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 standard(s) 18,19,20 and 21 The inspector was satisfied that the home is able to meet the personal and health care needs of service users. Service users have access to health care professionals as appropriate, although the home must ensure that medications are appropriately stored and recorded. EVIDENCE: All service users are able to manage their own personal care. Staff will encourage and prompt service users to attend to their personal care as appropriate, and offer guidance on dressing appropriately for the weather. All service users are registered with a GP. Records are kept of medical appointments, including any follow up action necessary. Records evidenced that service users have access to health care professionals as appropriate, including dentists, opticians and one service user has recently been working with a drugs and alcohol counsellor. The home has a policy in place on medication, and all staff undergo training before they are able to administer medication. No service users currently self medicate or are on any controlled drugs. Medications are stored in a cabinet in the office. On the day of the inspection this cabinet was found to be left unlocked, as was the office, and the office was unattended by staff. It is required that all medications are stored securely. Records are maintained of Companion In Care G56 G06 S43228 Companion In Care V246004 180905 Stage 4.doc Version 1.40 Page 12 medications entering the home and those that are returned to the pharmacist. Medication Administration Records (MAR) charts were maintained, these appeared to be accurate and up to date. However, it is required that all hand written entries on MAR charts are signed for. Staff informed the inspector that service users would be able to remain in the home with a terminal illness, as long as the home was able to meet their medical needs. Companion In Care G56 G06 S43228 Companion In Care V246004 180905 Stage 4.doc Version 1.40 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 standard(s) 22 and 23 It is the view of the inspector that adequate systems are in place to help ensure that service users are protected from adult protection issues. All staff have received training in adult protection, and the home has satisfactory procedures in place for dealing with complaints. EVIDENCE: The home maintains a complaints log, this evidenced that complaints have been appropriately recorded and addressed. The home has a complaints procedure, this was prominently displayed within the home. The procedure included timescales for responding to any complaints and contact details of the CSCI. Service users spoken to by the inspector demonstrated a good understanding of whom they could complain to if they so wished. The home has a copy of the Local Authorities adult protection procedures and also its own policy on adult protection. This appeared to be in line with current legislation. Since the previous inspection all staff at the home have now received training on adult protection issues, and staff spoken to demonstrated a good understanding of their roles and responsibilities with regard to adult protection. The home holds money on behalf of one service user in a locked cupboard. Records are maintained of the service users finances, those checked by the inspector appeared to be satisfactory. The service user signs for any monies they take. Companion In Care G56 G06 S43228 Companion In Care V246004 180905 Stage 4.doc Version 1.40 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 standard(s) 24,25,26,27,28,29 and 30 The inspector was satisfied that the home is suitable to meet its stated purpose. It is well maintained both internally and externally, and service users are provided with adequate communal and private space. EVIDENCE: The home is situated in a residential area of Leyton, in the London Borough of Waltham Forest. The home is in keeping with other homes in the vicinity, and is close to shops, transport links and other local amenities. All service users have their own bedrooms, these meet National Minimum Standards on size requirements, and have been decorated to service users personal tastes. Bedrooms had appropriate furniture, including table, chair, chest of draws and wardrobes; and bedding, carpet and curtains were well maintained. All bedrooms have hand basins fitted. Communal space consists of a kitchen/dining room, sitting room and a garden. Furniture and fittings around the home were generally well maintained and domestic in character. New floors have recently been purchased, which service users chose. Service users were free to move around communal areas as they wished. The home has one bathroom/toilet, one shower room and one toilet on Companion In Care G56 G06 S43228 Companion In Care V246004 180905 Stage 4.doc Version 1.40 Page 15 its own, the inspector believes this to be adequate to meet service users needs. Bathrooms were clean, tidy and free from offensive odour, and all had working locks fitted. Appropriate measures are in place to help control the spread of infection, for example hand washing facilities throughout the home, and protective clothing is provided for staff. Companion In Care G56 G06 S43228 Companion In Care V246004 180905 Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,34,35 and 36 It is the judgement of the inspector that the home is staffed in sufficient numbers to meet the needs of service users. Staff appeared to be sufficiently experienced and qualified, and have built up good relations with service users. EVIDENCE: The home provides 24-hour care, including an emergency on-call procedure. There was a staffing rota on display within the home, which accurately reflected the staffing situation on the day of inspection. The home has policies in place on equal opportunities and recruitment and selection. The recruitment and selection policy has been amended since the last inspection, and now states that service users will be involved in the recruitment of staff to the home, and is now in line with the homes actual practice with regard to staff recruitment. Staff employment files are stored in a locked cabinet in the home. Only the manager has access to this, and as the manager was not present during the inspection the inspector was unable to check staff employment records, but these will be checked as part of the next inspection. All staff are given a copy of their job description and the General Social Care Council codes of conduct. Staff spoken to demonstrated a good understanding of their roles and responsibilities. Through observation and discussion there was evidence that staff have built up good relations with individual service Companion In Care G56 G06 S43228 Companion In Care V246004 180905 Stage 4.doc Version 1.40 Page 17 users. The home holds regular staff meetings, these are minuted, and all staff are able to put items on the agenda. Recent meetings have included discussions on service users issues, health and safety and general house issues. Staff informed the inspector that they receive a structured induction when they commence working at the home, this covers service users, health and safety and the homes policies and procedures. Staff have access to regular training, records are maintained of staff training. These evidenced recent training in mental health, disruptive behaviour, medication and care planning. The inspector was informed that all three of the homes care staff are currently working towards relevant NVQ Care qualifications, and that two of these should be completed by the end of this year. All staff receive regular formal supervision from either the homes manager or deputy manager. Records are kept of supervisions, and staff get a copy of there supervision notes. Supervision covers service user issues, performance and training. At the last inspection a requirement was set that all staff receive an annual appraisal. It could not be evidenced that this has been done, and consequently this requirement is repeated in this report. Companion In Care G56 G06 S43228 Companion In Care V246004 180905 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) 38,39,40,41,42 and 43 It is the view of the inspector that this is a generally well managed home. Appropriate checks have been put in place with regard to health and safety, and record keeping is of a good standard. However, the home must ensure that monthly Regulation 26 visits take place. EVIDENCE: The homes manager has seven years experience of working with adults with mental health issues, including four years in a managerial capacity. They have successfully completed an NVQ Level 4 in Care. Staff and service users spoken to informed the inspector that they found the manager to be approachable and accessible. Care plan reviews, staff meetings and staff supervisions all contribute to the quality assurance within the home. The home uses questionnaires to gain service users feedback on the running of the home every six months. Those seen by the inspector were generally positive, although one service user Companion In Care G56 G06 S43228 Companion In Care V246004 180905 Stage 4.doc Version 1.40 Page 19 commented that they would like the discarded van that is parked in the homes driveway to be removed. The van does not belong to any of the service users, nor do they ever use it. This issue had also been raised in a service users meeting. The van is not in use, and obscures the view from the bedroom of the service user concerned, and it is required that it is removed. The home has not had a Regulation 26 visit since February of this year. It is a repeat requirement that the home has monthly unannounced Regulation 26 visits, and that a copy of the reports of these visits is sent to the CSCI, and a copy retained in the home. The home has policies and procedures in place in line with NMS. Those checked by the inspector included adult protection, recruitment and selection and medication. All appeared to be satisfactory. Records maintained appeared to be accurate and up to date. Confidential records are stored securely, and staff and service users can access their records as appropriate. Staff have received various health and safety training, including food hygiene and manual handling. The home has appropriate health and safety policies, such as on COSHH and fire safety. Fire fighting equipment was situated throughout the home, and last serviced in May 2005. Fire exits were clearly signed and on the day of inspection free from obstruction. The home holds regular fire drills, and fire alarms are checked weekly, and were last serviced by an engineer on the 12/3/05. The home has in date safety certificates on gas, PAT and electrical installation. Fridge/freezer temperatures are checked daily and hot water temperatures are checked weekly. COSHH products are stored securely. The home has in date employer’s liability insurance cover. Companion In Care G56 G06 S43228 Companion In Care V246004 180905 Stage 4.doc Version 1.40 Page 20 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 2 2 3 3 2 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x x x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 x x x x x x x Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Companion In Care Score 3 3 2 3 Standard No 37 38 39 40 41 42 43 Score x 3 2 3 3 3 3 G56 G06 S43228 Companion In Care V246004 180905 Stage 4.doc Version 1.40 Page 21 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 YA2 Regulation 14 Requirement The registered person must ensure that thorough pre admission assessments are carried out on all service users before they move into the home. (Timescale 22/8/05 not met) The registered person must ensure that service users contracts/statements of terms and conditions contain all information required by National Minimum Standard 5. (Timescale 22/8/05 not met) The registered person must ensure that comprehensive monthly Regulation 26 visits are carried out, and that a copy of the subsequent report is forwarded to the CSCI and a copy retained in the home. (Timescale 22/8/05 not met) The registered person must ensure that all staff receive an annual appraisal. (Timescale 22/8/05 not met) The registered person must ensure that the homes Service User Guide is in line with NMS 1. The registered person must ensure that all medications are stored securely. G56 G06 S43228 Companion In Care V246004 180905 Stage 4.doc Timescale for action 31/12/05 2. YA5 5 31/12/05 3. YA39 26 31/12/05 4. YA36 19 31/12/05 5. 6. YA1 YA20 5 13 31/12/05 31/12/05 Companion In Care Version 1.40 Page 22 7. YA20 13 8. YA39 23 The registered person must ensure that all hand written entries on MAR charts are signed. The registered person must ensure that the disused van is removed from the homes driveway. 31/12/05 31/12/05 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 Good Practice Recommendations Companion In Care G56 G06 S43228 Companion In Care V246004 180905 Stage 4.doc Version 1.40 Page 23 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. Extracts may not be used or reproduced without the express permission of CSCI Companion In Care G56 G06 S43228 Companion In Care V246004 180905 Stage 4.doc Version 1.40 Page 24 - 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. 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