Inspection on 10/01/06 for Dagenham Road

This inspection was carried out on 10th January 2006.

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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Dagenham Road 25/03/09

Dagenham Road 03/04/07

Dagenham Road 28/06/05

Dagenham Road 10/03/05

Dagenham Road 07/09/04

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 Dagenham Road 357A-359 Dagenham Road Romford Essex RM7 0XX Lead Inspector Ms Gwen Lording Unannounced Inspection 10th January 2006 09:30 Dagenham Road DS0000027897.V277261.R01.S.doc Version 5.1 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 Dagenham Road DS0000027897.V277261.R01.S.doc Version 5.1 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. Dagenham Road DS0000027897.V277261.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Dagenham Road Address 357A-359 Dagenham Road Romford Essex RM7 0XX 0208 595 5336 020 8984 8989 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) Outlook Care Pauline Dora Dean Care Home 8 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (8) of places Dagenham Road DS0000027897.V277261.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th June 2005 Brief Description of the Service: The home is situated in Dagenham Road, with easy access, by bus to Romford town centre or Dagenham Heathway. The home has two units of four beds each. In March 2003 the home changed from having three units to two residential care home units and one supported living unit. There is now a registered manager in post and support workers who staff the home; two support workers have worked at the home since it opened. There are places for 8 service users with mental health support needs; a new registration certificate has been issued to reflect these changes. The service user group at the time of inspection were semi-independent, needing prompting, reassurance and support from staff. The staff team work hard to ensure the service users independence is maintained, and liaise with other professionals to regulate service users health and wellbeing. The home is staffed 24 hrs a day with a waking member of staff at night. Outlook Care provides the support whilst East Thames Housing Group is the landlord. Dagenham Road DS0000027897.V277261.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and started at 9.30am. It took place over three hours during the morning and early afternoon. Discussion took place with the registered manager and two members of care staff. The Inspector spoke to two residents who were in the home on the day of the visit. Other residents were attending day activities and appointments away from the home and were not present during the visit. A tour of the home was made and a number of care and staff records were looked at. This was the second statutory inspection visit in the inspection programme for 2005/2006. Over the course of the two visits, all key standards have now been assessed. The Inspector would like to thank the staff and residents for their input during the inspection. What the service does well: What has improved since the last inspection? Both lounges have been completely refurbished with very attractive furniture and fittings, which the residents were involved in choosing. Both quiet lounges have been re-decorated and one of the downstairs shower rooms has been completely re-fitted. The registered providers, Outlook Care have recently appointed a Head of Care for mental health services. He is currently reviewing all mental health services in the organisation. The home manager is confident that this review will further Dagenham Road DS0000027897.V277261.R01.S.doc Version 5.1 Page 6 improve the quality of specialist mental health services within the organisation and the home. 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. Dagenham Road DS0000027897.V277261.R01.S.doc Version 5.1 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 Dagenham Road DS0000027897.V277261.R01.S.doc Version 5.1 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): Standards 2 and 3. The assessments completed by the home and the information and reports received from other health professionals means that staff have detailed information to enable them to determine whether or not the home can meet a prospective resident’s needs. EVIDENCE: Several residents have been living in the home since it opened in 2001. The most recent resident was admitted to the home in 2004. The file of this resident was examined and was found to contain a detailed assessment that had been undertaken prior to her admission to the home. The home had also received an assessment and care plan from the referring agency including involvement from the resident. Dagenham Road DS0000027897.V277261.R01.S.doc Version 5.1 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): Standard 6 Resident’s benefit from the attention paid by staff in identifying and meeting their personal, social support and health care needs. The individual plans of care for each resident would be improved by staff making more consistent use of the home’s pro-forma care planning documentation. Standards 7, 8, 9, and 10 were not tested on this visit. EVIDENCE: The above standards were not specifically tested on this visit, as there were no outstanding requirements in relation to Standards 7, 8, 9,and 10. At the time of the last inspection, all of the outcome standards were assessed as met. These standards will be re-tested at a future inspection. Each resident has an individual “person centred” plan of care and the care plans of three residents in the home were examined. The care plans cover in sufficient detail all aspects of personal, social support and health care needs of the individual resident. The care plan also sets out specialist requirements and how they are to be met. Care plans were being evaluated and regularly reviewed by the home and multi-disciplinary professionals and updated accordingly to reflect changing needs. Residents are actively involved in this process. The home has very comprehensive pro-forma care planning Dagenham Road DS0000027897.V277261.R01.S.doc Version 5.1 Page 10 documentation but not all sections were being completed fully on all files examined. For example, the section for recording visits to the GP and Well Woman Clinic was not completed however; this information was to be found in the daily entries. The individual plans of care for each resident would be improved by staff making more consistent use of the home’s pro-forma documents. Dagenham Road DS0000027897.V277261.R01.S.doc Version 5.1 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): Standards 15 and 17 Residents are provided with varied and nutritional meals, staff promote healthy eating and individual preferences are catered for. Visitors are made to feel welcome in the home and residents are supported to maintain and establish family links and friendships. Standards 12, 13, 14 and 16 were not tested on this visit. However, evidence from the last inspection was that: • Opportunities for social and leisure pursuits and personal development are actively promoted and supported by staff for all residents to enable them to participate in the wider community in which they live. EVIDENCE: The above standards were not specifically tested on this visit, as there were no outstanding requirements in relation to Standards 12, 13, 14 and 15. At the time of the last inspection, all of the outcome standards were assessed as met. These standards will be re-tested at a future inspection. Staff prepare and cook the meals with involvement from the residents and the menu for the week ahead is discussed at the weekend. Residents mainly Dagenham Road DS0000027897.V277261.R01.S.doc Version 5.1 Page 12 choose to have their main meal in the evenings as this suits individual residents activities and schedules. A range of drinks and snacks are available at all times and residents have full access to kitchen facilities. Residents can choose when and where to eat but usually eat in the large kitchen/ dining room with other residents and staff. One of the residents in the home is of the Muslim religion and staff purchase and cook halal meat and other culturally appropriate foods that she likes. There are no restrictions on visitors to the home and residents can receive visitors in their own rooms if they wish. Several residents have friendships with people who live at other homes provided by the organisation. Dagenham Road DS0000027897.V277261.R01.S.doc Version 5.1 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 the following standard(s): Standards 18, 19 and 20 were not tested on this visit. However, evidence from the last inspection was that: • The residents’ physical and emotional health care needs are closely monitored and this ensures that residents needs are recognised and met • The medication policies and procedures are clear and all staff have received training, ensuring the safety of residents. EVIDENCE: The above standards were not specifically tested on this visit, as there were no outstanding requirements in relation to all these standards. At the time of the last inspection, all of the outcome standards were assessed as met. These standards will be re-tested at a future inspection. Dagenham Road DS0000027897.V277261.R01.S.doc Version 5.1 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 the following standard(s): Standards 22 and 23 The manager and staff make every effort to sort out any problems or concerns and make sure that residents feel confident that their complaints and concerns are listened to and will be acted upon. The new complaints policy specifically produced for residents, must be amended to provide information for referring a complaint to the Commission at any stage, should the complainant wish to do so. Staff working in the home have received training in Adult Protection/ Abuse Awareness and this ensures that there is a proper response to any suspicion or allegation of abuse. EVIDENCE: The home has policies and procedures for dealing with complaints and the records examined showed that all complaints, both verbal and written, are recorded with full details of investigation, any action taken and the outcome for the complainant. Two residents spoken to about what they would do if they were unhappy with anything said that they would “speak to Pauline or Raj” (manager and care worker) The registered providers Outlook Care, have recently developed a number of core policies in a format specifically for residents. This includes a complaints policy with information about how to contact the Commission, if the complainant remains dissatisfied with the outcome of any investigation. However, this policy must be amended to provide information for referring a complaint to the Commission, at any stage, should the complainant wish to do so, in line with Standard 22.3. Dagenham Road DS0000027897.V277261.R01.S.doc Version 5.1 Page 15 There is a written policy and procedure for dealing with allegations of abuse and whistle blowing. All staff working in the home have received training in Adult Protection/ Abuse Awareness. Those staff spoken to during the inspection were aware of the action to be taken if there were concerns about the welfare and safety of residents. Dagenham Road DS0000027897.V277261.R01.S.doc Version 5.1 Page 16 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): Standards 24, 27 and 30 were not tested on this visit. However, evidence from the last inspection was that: • The décor, furnishings and fittings in the home are of a very good standard and provide a comfortable and homely environment for residents to live. EVIDENCE: The above standards were not specifically tested on this visit, as there were no outstanding requirements in relation to all these standards. At the time of the last inspection, all of the outcome standards were assessed as met. These standards will be re-tested at a future inspection. Dagenham Road DS0000027897.V277261.R01.S.doc Version 5.1 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 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): Standards 33, 34 and 35 were not tested on this visit. However, evidence from the last inspection was that: • • Staffing levels are satisfactory and there is sufficient staff on duty to meet the individual needs of the residents. The procedures for the recruitment of staff are robust and provide safeguards for people living in the home. EVIDENCE: The above standards were not specifically tested on this visit, as there were no outstanding requirements in relation to all these standards. At the time of the last inspection, all of the outcome standards were assessed as met. These standards will be re-tested at a future inspection. Dagenham Road DS0000027897.V277261.R01.S.doc Version 5.1 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 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): Standards 39 & 42 The home is well managed and residents benefit as the home is run in their best interests and does not significantly impact upon the safety of residents in the home. EVIDENCE: Standard 37 was not specifically tested on this visit, as there were no outstanding requirements in relation to this standard. At the time of the last inspection, all of the outcome standards were assessed as met. This standard will be re-tested at a future inspection. A range of records were looked at including fire safety, accident/ incident reports and the recording of the temperature of hot water outlets. These records were detailed, up to date and accurate. There is a quality assurance system in place, which includes seeking the views of residents through, regular house meetings and their attendance at forums such as the Mental Health Service User Forum. Two residents from the home Dagenham Road DS0000027897.V277261.R01.S.doc Version 5.1 Page 19 were due to attend this forum later in the evening. Quality assurance surveys are undertaken and the results are published with opportunities for discussion with both staff and people using the service. The registered providers also check the quality of care in the home through monthly Regulation 26 monitoring visits. These reports are comprehensive and a copy is sent to the Commission. Dagenham Road DS0000027897.V277261.R01.S.doc Version 5.1 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 Standard No Score 1 X 2 3 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X X X 3 X X 3 X Dagenham Road DS0000027897.V277261.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? NO 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 2 Standard YA6 YA22 Regulation 15 22 Timescale for action Staff must make more consistent 13/02/06 use of the home’s pro-forma care planning documentation The complaints policy specifically 13/02/06 developed for residents, must be amended to include information for referring a complaint to the Commission, at any stage, should the complainant wish to do so. Requirement 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 Dagenham Road DS0000027897.V277261.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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 Dagenham Road DS0000027897.V277261.R01.S.doc Version 5.1 Page 23 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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