Inspection on 08/11/05 for Croydon Road,78

This inspection was carried out on 8th November 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Croydon Road,78 12/06/07

Croydon Road,78 09/05/06

Croydon Road,78 04/05/05

Croydon Road,78 01/11/04

Croydon Road,78 25/05/04

Croydon Road,78 02/10/03

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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 Croydon Road,78 78 Croydon Road Penge London SE20 7AB Lead Inspector Miss Rosemary Blenkinsopp Unannounced Inspection 8th November 2005 09:30 Croydon Road,78 DS0000006909.V259953.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 Croydon Road,78 DS0000006909.V259953.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. Croydon Road,78 DS0000006909.V259953.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Croydon Road,78 Address 78 Croydon Road Penge London SE20 7AB 020 8676 9965 020 8676 9965 claire.fakhet@community-options.org.uk 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) Community Options Limited Mr K Pathmanathan Care Home 7 Category(ies) of Past or present alcohol dependence (7), Past or registration, with number present drug dependence (7), Mental disorder, of places excluding learning disability or dementia (7) Croydon Road,78 DS0000006909.V259953.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4 May 2005 Brief Description of the Service: This home is part of the Community Options group. Community Options has a number of facilities in the Bromley area. The home has its own dedicated manager and staff team, whilst senior management and personal support are provided centrally. The home is a detached house in a residential area of Penge. It is located close to the High Street and is well served by public transport. The building itself is located over three floors accessed by stairs. There are no adaptations in this home as all residents are primarily younger adults undergoing rehabilitation. The purpose of the home is rehabilitation to enable residents to live independently. Residents in this home have mental health disorder and are subject to the Care Programme Approach. This is a system of multi-disciplinary monitoring and review to keep abreast of the individuals mental health. Staff are provided throughout the 24-hour period, including waking staff. All other health care support is provided through the community. Croydon Road,78 DS0000006909.V259953.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted unannounced. At the time of the inspection the manager was on duty with the deputy manager. Another staff was out of the home. The two managers facilitated the inspection jointly. Residents were coming and going during the inspection. The inspector met with two residents and one other briefly. No bedrooms were inspected as they were unoccupied and locked and one residents did not want the inspector to view his bedroom. Communal areas were inspected and specifically the kitchen as at the last inspection insufficient equipment had been available. One care plan and associated risk assessment documentation was inspected, and found not to be to a satisfactory standard. This has resulted in the previous requirements being repeated. In addition the requirement relating to staff training is partially met, as statutory manual handling training was overdue. What the service does well: What has improved since the last inspection? What they could do better: The care plan documentation is still not fully reflective of residents’ needs. Risk assessments and other supporting documentation are not sufficiently robust to afford protection to either the residents or the staff. The inspector has been advised that new care plan documentation is being addressed although to date this has not become operational. Croydon Road,78 DS0000006909.V259953.R01.S.doc Version 5.0 Page 6 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. Croydon Road,78 DS0000006909.V259953.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 Croydon Road,78 DS0000006909.V259953.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): 1. The Statement of Purpose provided sufficient information for residents and relatives. EVIDENCE: The Statement of Purpose was inspected. It included details of the manager, Claire Fakhet; she has not yet completed the CSCI process to become the registered manager. The information on staffing needed to be updated as the home now has a full complement of staff and therefore the new staff need to be included. The other items as detailed under Schedule 1, Care Standard Act 2000, were included. In one care plan there was a copy of the resident’s terms and conditions of residency. Croydon Road,78 DS0000006909.V259953.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. Care plans are not sufficiently comprehensive in detail or supported by robust risk assessments to reflect residents’ needs. EVIDENCE: The residents in this home usually have a maximum of two years before they move onto more independent living accommodation. All of the seven residents in the home are on Enhanced Care Programme Approach (CPA). Care Programme Approach is a system of after care for those residents suffering mental heath issues. The care plan of the last admission to the home was inspected. He had been admitted 30 August 2005, prior to this he had been in Green Parks hospital. The resident’s care plan had no issues identified under the section “My support plan”. When asked about this staff said that the care plan was still being fully developed and that because of the title “ My support plan”, they felt the onus was on the residents. This is not acceptable. All residents must have an initial care plan in pace within 24 hours. The care plan can be added to as more information is known about the resident and reviewed as required. The staff were aware of this gentleman’s problems and in fact said that since his Croydon Road,78 DS0000006909.V259953.R01.S.doc Version 5.0 Page 10 admission several other areas which needed intervention, had come to light. The care plan reflected none of this. His risk assessments identified one issue although, again, staff could identify several areas of risk. The identified risk assessments were of significance as it could cause injury to himself or to others. However other issues related to the inspector left the resident equally vulnerable. One other area of risk had the risk identified but no further information or intervention to reduce the risk. Other information, which was incomplete, included the contact sheet for those people and professionals important to the resident. Please see requirements 1 and 2. Croydon Road,78 DS0000006909.V259953.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): 13,15,16. It was evident that residents are encouraged to become involved in the local community, access local facilities and maintain family contact. EVIDENCE: One resident had a long conversation with the inspector. She had just returned from an overnight stay at her sisters. She was eager to move on from the home. She related to the inspector how she spent her day. She had recently attended the Community Options AGM, in which she had participated and enjoyed. She said that she was assisted in some activities of daily living and had freedom to come and go within reason. Visiting is open. Another residents was keen on recycling and talked to the inspector about this. The general feeling was that the residents in this home did not want to attend the local day centres or MIND. No meals were observed at this inspection, although the kitchen equipment was checked. There are still limited quantities particularly in the amount of cutlery. Residents who are under going rehabilitation need the correct utensils to enable this. Please see requirement 3. Croydon Road,78 DS0000006909.V259953.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): 20,21. All healthcare is accessed through the local community provision, which for this type of resident is appropriate. EVIDENCE: All healthcare provision is accessed though the local community as part of on going rehabilitation. Those residents, who are under the CPA after care systems, have a care co-ordinator who conducts regular reviews and monitors progress on their care plan. This system ensures that residents are followed up and care plans are revised Other healthcare provision such as GP, dentist and chiropodist is through the local PCT. There is a policy on death and dying although this states “under review”. This should be made final as soon as possible. The medication systems were inspected. Generally the information required was in place with the exception of one resident’s photograph. Those medications, which are hand transcribed, should have two staff signatures in place to confirm the accuracy of the information recorded. Please see recommendation 1. Croydon Road,78 DS0000006909.V259953.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): 22,23. Systems are in place by which residents can raise concerns. Staff are sufficiently training to recognise and action suspected abuse. EVIDENCE: There have been no complaints made to the CSCI regarding this service. The home has its own complaints procedure, which includes details of the CSCI. All staff, with the exception of two new employees, have undertaken training on abuse. The training was provided through the local Social Services department. The course was two days covering suspicion of abuse and one day on adult protection. Staff with whom the inspector met felt it was useful and were aware of the actions to take. Community Options have their own policy on abuse. The majority of residents have next of kin. There are no residents who have an independent advocate currently. Two residents’ finances were checked and found to be correct with receipts available. Two signatures were in place for transactions, that of the resident and the staff member. One resident had an appointee for his financial dealings. Croydon Road,78 DS0000006909.V259953.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): 28,29,30. The home is maintained in a domestic homely manner although cleanliness could be improved. EVIDENCE: The inspector viewed the kitchen. It was clean and tidy. It is noted that there were several sauce pans although little cutlery. Staff said they had replaced every item following the last inspection and again residents had disposed of them as opposed to washing them up. Systems should be in place to offer sufficient supervision to residents whilst in the kitchen The dining area and lobby area beside it were not to a hygienic standard. There were ash and crumbs on the floor and a cup was full of cigarette ends. The lounge was tidy and comfortable. Residents are supported to do the household chores as part of rehabilitation programmes. Please see requirement 3. Croydon Road,78 DS0000006909.V259953.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): 33,34,36. The staffing levels in the home are provided in sufficient numbers to address residents’ needs. Training is appropriate to the resident group and supported by Community Options. EVIDENCE: The staff personnel files had been inspected at Community Options head office and found to be to a satisfactory standard. The staff team are now at a full complement; there are ten full time staff now in post. Recently the home has used no agency or bank staff. The home operates with two staff in the morning and three in the afternoon, with two night staff, one of whom is sleeping in. The manager is supernumerary to these numbers. New staff have the company induction and TOPPS. All employees have an individual training plan and topics are discussed through supervision. Recent training has included topics specific to residents’ needs and mandatory items. The training for manual handling has expired for seven staff this needs to be addressed. Within the staff team two staff have completed NVQ level 2 and one level 3. Four other staff are either doing, or due to start, NVQ 2 or 3. Please see requirement 4. Croydon Road,78 DS0000006909.V259953.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): 38,40. The permanent manger is suitably experienced in working with the residents group. EVIDENCE: Claire Fakhet is the appointed manager for this facility. She has worked in this home for several years. Claire has completed the HNC in social care, NVQ level 3, and is currently undertaking the NVQ assessor’s course. Policies and procedures are generated through the central office and a standard format. Croydon Road,78 DS0000006909.V259953.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 2 X X X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X 3 2 2 LIFESTYLES Standard No Score 11 X 12 X 13 3 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X X 3 3 X 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Croydon Road,78 Score X X 3 3 Standard No 37 38 39 40 41 42 43 Score X 2 X 3 X X X DS0000006909.V259953.R01.S.doc Version 5.0 Page 18 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 YA6 Regulation 15 Requirement Timescale for action 30/12/05 2. YA9 13 3. YA29 16 4. YA32 18 The Manager must ensure resident’s care plans are comprehensive in content and reflective of identified needs. Previous time frame 31/12/2004. This is now outstanding. The Manager must ensure that 30/12/05 risk assessments are comprehensive in content to reduce the assessed risk. Previous timeframe 31/12/2004. This is now outstanding The Manager must ensure that 30/11/05 sufficient equipment is available for residents use. Partially met. The manager must ensure the environment is maintained to a satisfactory standard. The Manager must ensure that 30/11/05 all training is current, particularly the manual handling updates. Croydon Road,78 DS0000006909.V259953.R01.S.doc Version 5.0 Page 19 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 YA20 Good Practice Recommendations The Manager should ensure that those medications, which are hand transcribed, have two staff signatures in place to confirm the accuracy of the information recorded. Croydon Road,78 DS0000006909.V259953.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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