Inspection on 15/11/05 for Coxley House

This inspection was carried out on 15th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 17 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Coxley House 22/08/06

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 Coxley House 28 Bow Road Bow London E3 4LN Lead Inspector Lea Alexander Unannounced Inspection 15th November 2005 11:00 Coxley House DS0000063898.V264864.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 Coxley House DS0000063898.V264864.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. Coxley House DS0000063898.V264864.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Coxley House Address 28 Bow Road Bow London E3 4LN 020 8980 1599 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) East Living Limited Mr Adusei Attah-Poku Care Home 13 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (13), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (2) Coxley House DS0000063898.V264864.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Can provide care for three (3) named service users over the age of 65 years. 6th May 2005 Date of last inspection Brief Description of the Service: Coxley House is a purpose built care home offering accommodation and support to thirteen service users with mental health difficulties. The home is built over two floors and comprises 13 flatlets. Each flat is open plan with a kitchenette, bedroom/sitting area and private bathroom comprising of wc and handbasin. There are an additional three shared bathrooms and a shared shower room that service users can access. There is a large a ground floor, open plan, communal area that has a dining area and main kitchen at one end and a sitting area and service user kitchen at the other. On the upper balcony there is a second sitting area with mezzanine walkway to an art area. From the dining area there are french windows into a pleasant courtyard garden. The home is situated on the Bow Road with good public transport links. Since the last inspection the home has transferrd from the Springboard housing organisation to East Thames. The staff and service user group remain unchanged as a result of this transfer. Coxley House DS0000063898.V264864.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection conducted by one inspector over the course of a morning. The main focus of this inspection was to review progress in addressing the 16 requirements made at the last inspection. This report should be read in conjunction with the inspection report of the 6th May 2005. During the course of the inspection the Inspector sampled service users files, toured the premises, met with the senior staff member on duty and spoke with seven service users. The Inspector would like to thank service users and staff for their assistance with this Inspection. What the service does well: What has improved since the last inspection? What they could do better: Fifteen requirements were restated and further two requirements made as a result of this inspection. Key policies and procedures must be available at all times to staff and service users. During this inspection they were unavailable, being locked in the Manager’s office was on leave. All the requirements regarding revision of policy and procedure were automatically restated. The Inspector was disappointed to note that requirements made at the previous inspection regarding the content of individual service users plans and risk assessments and the frequency with which these are addressed had not been addressed. Coxley House DS0000063898.V264864.R01.S.doc Version 5.0 Page 6 The communal areas should be personalised to reflect the current service user group and give the home a less institutionalised feel. Carpets in the communal areas are badly stained and should be replaced. A programme of redecoration and refurbishment must be planned and undertaken for service users rooms and communal bathrooms. Service users should be supported to maintain a hygienic odour free environment in their own rooms. 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. Coxley House DS0000063898.V264864.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 Coxley House DS0000063898.V264864.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): 4. EVIDENCE: There have been no admissions to the home since the last inspection. The Inspector was unable to review the homes admission policy as this was in the manager’s office that staff cannot access in their absence. Key standard 2 was not inspected on this occasion. It was inspected on the 6th May 2005 and met. Coxley House DS0000063898.V264864.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 & 9. Service users individual plans and risk assessments are not being regularly reviewed and updated. EVIDENCE: The Inspector sampled two service users personal files. One of these contained an individual service user plan that had been reviewed in June 2005 and included information on how the key worker would support them. The second service users personal file contained an individual plan dated August 2004. It was not evidenced that this had been reviewed in the intervening period. Both of the service users files sampled contained risk assessments dated August and September 2004. It was not evidenced that these had been updated in the intervening period or in the case of one of the service users, reviewed in conjunction with their individual plan. Key standard 7 was not inspected on this occasion. It was inspected on the 6th May 2005 and met. Coxley House DS0000063898.V264864.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): 16. Service users report that they like living in the home. EVIDENCE: The Inspector was unable to access the homes policies and procedures in the manager’s absence, and a requirement regarding clarification of overnight guests in the visitor’s policy is restated. All the service users spoken to by the Inspector said they liked living at the home. Many of them expressed their enjoyment of the homes art group that is run by a visiting therapist. One service user commented that “this is a nice place to live”, and another that they had “freedom to live”. Key standards 12, 13, 15 and 17 were not inspected on this occasion. They were inspected on the 6th May 2005 and met. Coxley House DS0000063898.V264864.R01.S.doc Version 5.0 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 & 21. Key policies and procedures are not always available for staff or service users to access. The homes does not adequately record information about self-medication in service users individual plans or complete risk assessments for this activity. EVIDENCE: The Inspector was also unable to access the homes medication policy or protocol to address ageing, illness and death in the manager’s absence. Requirements in these areas are therefore restated. The Inspector sampled the personal file for a service user who is self medicating. It was not evidenced that their self-medication is identified in their care plan or subject to risk assessment. Requirements from the previous inspection regarding this area are therefore restated. Key standards 18 and 19 were not inspected on this occasion. They were inspected on the 6th May 2005 and met. Coxley House DS0000063898.V264864.R01.S.doc Version 5.0 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Key standards 22 and 23 were not inspected on this occasion. They were inspected on the 6th May 2005 and met. Coxley House DS0000063898.V264864.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 29 & 30. The communal areas in the home have been redecorated but service users flats have not. Communal areas appear institutional in appearance. Shared bathrooms need renovation and decoration. EVIDENCE: The home is purpose built and provides individual privacy and spacious communal areas. Since the last inspection the communal areas have been redecorated. Thought needs to be given to the personalisation of these areas to reflect the service user group, as they have an institutionalised feel. The Inspector visited four service users rooms. These have not been decorated since the last inspection and in many rooms the furniture was not chosen by the service user and is dated, cumbersome and broken. Carpets in the communal areas remain stained and have not been replaced. The Inspector viewed all of the shared bathrooms. The previous inspection had required renovation and redecoration of these, and this remains outstanding. Coxley House DS0000063898.V264864.R01.S.doc Version 5.0 Page 14 A previously unused bathroom has been converted into a walk in shower since the last inspection. The Inspector noted that the home was generally clean and hygienic. However, there was a strong smell of urine in one service users room and staff must ensure that any support needs in this area are appropriately addressed within the individual service users plan. Coxley House DS0000063898.V264864.R01.S.doc Version 5.0 Page 15 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): 34 & 36. EVIDENCE: In the manager and deputy managers absence staff personnel files were appropriately secured. The Inspector was therefore unable to determine progress with regard to the recording of personnel information or the frequency of supervision. Requirements made in these areas are therefore restated. The service users spoken to by the Inspector spoke very positively about staff. Comments included “staff are very kind” and “staff are very supportive and encouraging”. Key standard 35 was not inspected on this occasion. It was inspected on the 6th May 2005 and met. Standard 32 was identified as a key standard after two inspections were completed on this home. It has not therefore been assessed during this inspection cycle. Coxley House DS0000063898.V264864.R01.S.doc Version 5.0 Page 16 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39 & 43. Managerial documents and tools were not available in the Managers absence during this inspection. EVIDENCE: In the manager’s absence monthly visit reports from the responsible individual and the homes business plan were not available. Requirements in these areas are therefore restated. Key standards 37 and 42 were not inspected on this occasion. They were inspected on the 6th May 2005 and met. Coxley House DS0000063898.V264864.R01.S.doc Version 5.0 Page 17 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 2 X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X 2 2 X 3 2 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 2 17 Standard No 31 32 33 34 35 36 Score X X X 2 X 2 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Coxley House Score X X 2 2 Standard No 37 38 39 40 41 42 43 Score X X 2 2 X X 2 DS0000063898.V264864.R01.S.doc Version 5.0 Page 18 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 YA4 Regulation 14(1) Requirement The home must develop its admissions policy to include details of trial periods for service users and the process for initial introduction of service users to the home. This is a restated requirement. The previous target of the 06/11/05 was not met. 2 YA6 14(2) Service users plans must be reviewed at least every six months. This is a restated requirement. The previous target of the 06/11/05 was not met. 3 YA9 14(2) Risk assessments must be reviewed in the context of the service users individual plan and contain sufficient information. This is a restated requirement. The previous target of the 06/11/05 was not met. 4 YA16 12 & 13 The home must clarify its policy regarding overnight visitors. DS0000063898.V264864.R01.S.doc Timescale for action 31/03/06 31/03/06 31/03/06 31/03/06 Coxley House Version 5.0 Page 19 This is a restated requirement. The previous target of the 06/11/05 was not met. 5 YA20 13(2) The home must develop its medication policy to include partial self-medication and selfmedication. This is a restated requirement. The previous target of the 06/11/05 was not met. 6 YA20 13(2) Self-medication and partial selfmedication should be subject to a risk assessment and risk management framework. This is a restated requirement. The previous target of the 06/11/05 was not met. 7 YA21 12 & 13 A protocol to address issues of ageing, illness and death with service users must be developed. This is a restated requirement. The previous target of the 06/11/05 was not met. 8 YA24 23(2)(d) Stained carpets must be cleaned or replaced. This is a restated requirement. The previous target of the 06/11/05 was not met. 9 YA24 23(2)(d) With service users agreement and involvement their flats must be redecorated. This is a restated requirement. The previous target of the 06/11/05 was not met. 10 YA26 23(2)(c) Each service users flat must be provided with suitable furniture DS0000063898.V264864.R01.S.doc 31/03/06 31/03/06 31/03/06 31/03/06 31/03/06 31/03/06 Coxley House Version 5.0 Page 20 and fittings. This is a restated requirement. The previous target of the 06/11/05 was not met. 11 YA27 23(2)(j) The homes shared bathrooms require renovation and redecoration. This is a restated requirement. The previous target of the 06/11/05 was not met. 12 YA30 23(2)(d) The home, including service users rooms, must be kept free of offensive odours. 31/01/06 31/03/06 13 YA34 19 All personnel recruitment records 31/03/06 are kept centrally. The manager must ensure that a completed checklist of this recruitment information is available on site for each staff member. This is a restated requirement. The previous target of the 06/11/05 was not met. 14 YA36 18(2) Staff must receive regular supervision meetings, and a minimum of six of these sessions per year. This is a restated requirement. The previous target of the 06/11/05 was not met. 31/03/06 15 YA39 26 The responsible individual must visit the home on a monthly basis and copy reports of these visits to the Commission for Social Care Inspection. This is a restated requirement. The previous target of the 06/11/05 was not met. 31/03/06 Coxley House DS0000063898.V264864.R01.S.doc Version 5.0 Page 21 16 YA40 12(1)(a) The homes policies and procedures must be available to staff and service users at all times. The home must develop a business plan. This is a restated requirement. The previous target of the 06/11/05 was not met. 31/01/06 17 YA43 25(1) 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Coxley House DS0000063898.V264864.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection East London Area Office Gredley House 1-11 Broadway Stratford 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 Coxley House DS0000063898.V264864.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. 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