Inspection on 02/12/05 for De Lucy Street (5)

This inspection was carried out on 2nd December 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 no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

De Lucy Street (5) 09/03/07

De Lucy Street (5) 15/02/06

De Lucy Street (5) 14/02/05

De Lucy Street (5) 28/09/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 De Lucy Street (5) 5 De Lucy Street Abbeywood London SE2 9ER Lead Inspector Keith Izzard Unannounced Inspection 2nd December 2005 09:30 De Lucy Street (5) DS0000036880.V272414.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 De Lucy Street (5) DS0000036880.V272414.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. De Lucy Street (5) DS0000036880.V272414.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service De Lucy Street (5) Address 5 De Lucy Street Abbeywood London SE2 9ER 020 8311 1571 020 8311 1571 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) Greenwich Council Mrs Della Vallery Nolan Care Home 4 Category(ies) of Learning disability (4) registration, with number of places De Lucy Street (5) DS0000036880.V272414.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th February 2005 Brief Description of the Service: The home is situated in a residential area, within easy reach of local amenities and public transport facilities. It is a two-storey, purpose built end of terrace property, which opened initially in November 1988. It has two single bedrooms on the ground floor, two single bedrooms on the upper floor, two bathrooms with WC’s, a lounge, kitchen/diner and a laundry room. The house has a garden to the rear and off-street parking for two vehicles. The property is owned by London and Quadrant Housing Association and managed by Greenwich Social Services under the Greenwich Living Options Scheme. The home accommodates four adult service users of both sexes on a long- term placement basis and there are no vacancies currently. De Lucy Street (5) DS0000036880.V272414.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first of two planned but unannounced inspections for this home in the year 1st April 2005 – 31st March 2006. The inspection took place over a period of four and a half hours and included a tour of the building and examination of service user care files, an interview with the manager and brief discussion with one member of staff. Only key Standards were assessed and any not assessed at this inspection will be at the next inspection, sometime prior to 31st March 2006. Both reports should therefore be read in conjunction with each other. Nine response questionnaires were returned to the CSCI and these provided favourable comments regarding the home and the service provided. What the service does well: What has improved since the last inspection? What they could do better: De Lucy Street (5) DS0000036880.V272414.R01.S.doc Version 5.0 Page 6 A recent visit and report by the local fire officer has required that automatic closure mechanisms are fitted to doors and the upstairs bathroom door is properly fire sealed. A recent Environmental Health Officer report has required that a separate small hand - washing sink is installed in the kitchen area. One first floor ceiling light requires repair and the other relocated for safety reasons. Following a risk assessment completed by the manager, a lock must be fitted to the kitchen utensil drawer to ensure the safety of service users. Recommendations were made that one service user has an Occupational Therapist assessment regarding access to the vehicle provided for service users and continued efforts are maintained to recruit staff members that are able to drive the vehicle to facilitate outings. 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. De Lucy Street (5) DS0000036880.V272414.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 De Lucy Street (5) DS0000036880.V272414.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&2 Adequate information was provided about the service in the statement of purpose and service user guide to enable prospective residents to make a decision to the suitability of the service. Admission procedures were in place to comply with these standards. EVIDENCE: The home had a statement of purpose and service user guide these are up to date and met the Standard. The admission procedures in place complied with the requirement of this Standard. As no new residents had been admitted since the introduction of the National Minimum Standards the procedures had not been implemented and could therefore not be assessed in practice. The manager is aware of the requirements should any new residents be admitted to the home. De Lucy Street (5) DS0000036880.V272414.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): 6,7 & 9 Care plans and risk assessments were available for all residents, they were comprehensive and up to date. Residents were involved with decisions made about their lives and lifestyle. EVIDENCE: Two care files and individual plans were examined in respect of two service users. Individual plans were comprehensive and involved service users and their representatives, including family or advocates and other professionals involved. These plans are reviewed with outcomes clearly stated and agreed by all participants. Records seen were comprehensive and up to date. Any restrictions placed are few and would be for the safety and welfare of service users, for example leaving the home unaccompanied. Evidence was available from the service user’s records examined that they are enabled to express choice in what they do and staff record these occasions. On a daily basis staff do make attempts to involve service users in the running of the home this is evidenced in the daily diaries for residents but is limited to minor domestic tasks such as putting clothes away helping with cleaning and De Lucy Street (5) DS0000036880.V272414.R01.S.doc Version 5.0 Page 10 meal preparation depending on ability and this would always be under the direct supervision of staff members. Enabling service users to express their choice in relation to outings, meals and activities are promoted by showing pictures and direct reference to specific items and the historical knowledge built up by staff members about individuals and recorded in their care files. Risk assessments are available in all service user’s care files and are easily available for all bank or agency staff who may be less familiar with service user’s needs. De Lucy Street (5) DS0000036880.V272414.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): 12-17 Attention was given to meeting the leisure and social needs of the residents. Meals provided were varied and planned to meet the resident’s choice and preferences. EVIDENCE: All four, service users attend day centres where they have the opportunity to develop life skills. Staff supported residents to develop daily living skills in line with their individual ability. Records showed and residents communicated that they were supported to access leisure activities of their choice and to integrate with the community. A range of outings, for example, visits to pubs, cinemas, shops, parks, football games, sightseeing and an annual holidays were recorded including residents’ comments on how they enjoyed these events. Continued efforts should be made to recruit permanent staff to the home able to drive the vehicle provided for service users. See Recommendation 1. Residents were enabled to choose their own clothes and hairstyles, when accompanied by staff members on shopping tips. Residents were also supported to choose their own decoration and personal items for their own rooms. De Lucy Street (5) DS0000036880.V272414.R01.S.doc Version 5.0 Page 12 Residents were supported to maintain positive relationships with their family and the manager has referred individual residents to the local advocacy and befriending services where appropriate. The manager reported that regrettably there are still delays being experienced in the provision of advocates. Varied and nutritious meals were provided to meet resident preferences and a rota of meals provided was seen over a period of four weeks and a good supply of both fresh and frozen food was seen stored in the home. None of the service users require a special, or culturally appropriate diet, but some require their food to be cut up and two require specific assistance from staff to enable them to eat safely and ensure adequate intake. Relevant risk assessments addressed these issues and had been completed by a member of the speech and language therapy service to advise staff members. De Lucy Street (5) DS0000036880.V272414.R01.S.doc Version 5.0 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): 18,19 &20 Resident’s needs were being met based on assessment of need and with the involvement of the resident, as far as this could be achieved, as most residents have severe communication difficulties. Medicines were assessed as safely managed on the day of inspection. EVIDENCE: Care plans showed the level of personal care required and how this was to be provided. The care plans examined were up to date and included comprehensive risk assessments. Residents were supported to access health services appropriately and had these provided either in the home or attended local clinics and surgeries. Evidence was available of hospital appointments that had been organised and for follow up of medical conditions in respect of three of the service users within their daily diaries and appointments book. Medicines were generally well managed in respect of the one service user who receives regular medication, the MAR sheet were examined and showed that medication had been given accurately and this was recorded appropriately. The system for receiving and disposal of unused medication was in place and staff recently had updated training in medication organised by a Boots De Lucy Street (5) DS0000036880.V272414.R01.S.doc Version 5.0 Page 14 Pharmacist. Medication is retained within a lockable cabinet designed for the purpose within the kitchen area. De Lucy Street (5) DS0000036880.V272414.R01.S.doc Version 5.0 Page 15 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 Adequate systems were in place to ensure residents were protected from abuse and to manage complaints about the service. EVIDENCE: The home had local policies and procedures to deal with complaints and allegations of abuse. Staff members have received training on adult protection and any suspicions or allegations of abuse would be referred to the Greenwich Community learning disability team for investigation. There were no allegations of abuse made about the service to the home or the Commission since the last inspection. No complaints had been received by the home. Accidents records were well maintained and any unexplained injuries would be referred to CDLT for investigation. De Lucy Street (5) DS0000036880.V272414.R01.S.doc Version 5.0 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): 24-30 Service users live in a homely and comfortable environment that is safe clean and hygienic. However, a new flat screen television is required in the communal lounge area and two ceiling lights need attention on the landing area, one to be relocated. The home must also implement the requirements of the recent fire officer and Environmental Health officer reports. A lock must be fitted to the kitchen utensil drawer. The premises were homely in appearance and decorated to a satisfactory standard. Individual and communal accommodation suited residents’ needs. EVIDENCE: De Lucy Street (5) DS0000036880.V272414.R01.S.doc Version 5.0 Page 17 A recent visit and report by the local fire officer has required that automatic closure mechanisms are fitted to doors and the upstairs bathroom door is properly sealed. See Requirement 1. A recent Environmental Health Officer report has required that a separate small hand - washing sink be installed in the kitchen area, this must be complied with. See Requirement 2. One first floor ceiling light requires repair and the other relocated for safety reasons. See Requirement 3. Following a risk assessment completed by the manager, a lock must be fitted to the kitchen utensil drawer to ensure the safety of service users. See Requirement 4. A new television is required to be fixed to the wall in the communal lounge area and the manager stated that this matter was already in hand. Standard 25 was met as there have not been any changes since the registration of the home. All service users have single rooms there is no multiple occupancy. All bedrooms occupied by service users were seen by the Inspector, during a tour of the building, and they had all been personalised and were tastefully furnished and decorated. A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. None of the current service users have any mobility needs requiring the provision of specialist adaptations or mobility equipment excepting one service user who should be assessed by an OT in respect of gaining access to the vehicle provided for service users. See Recommendation 2 The home has a washing machine with a sluicing facility and overall, the home was clean and tidy on the day of inspection. De Lucy Street (5) DS0000036880.V272414.R01.S.doc Version 5.0 Page 18 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): None of these Standards were assessed on this occasion but the key Standards will be at the next inspection. EVIDENCE: De Lucy Street (5) DS0000036880.V272414.R01.S.doc Version 5.0 Page 19 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): 42 EVIDENCE: A number of records to do with safety and maintenance were seen by the Inspector and were found to be up to date and well recorded. The manager confirmed that all staff had annually updated fire training and that night- time care staff had been included in at least two fire drills within the past year. Four requirements were made; See Standard 24 in relation to health and safety matters that must be com[plied with. De Lucy Street (5) DS0000036880.V272414.R01.S.doc Version 5.0 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 3 3 X X x Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X X X X X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 De Lucy Street (5) Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score X X X X X 2 x DS0000036880.V272414.R01.S.doc Version 5.0 Page 21 NO 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 YA24 Regulation 23 Requirement Automatic closure mechanisms must be fitted to doors and the upstairs bathroom door is properly fire sealed in accordance with Fire officer report. The recent Environmental Health Officer report has required that a separate small hand - washing sink is installed in the kitchen area. One first floor ceiling light requires repair and the other relocated for safety reasons. A lock must be fitted to the kitchen utensil drawer to ensure the safety of service users. Timescale for action 01/03/06 2 YA24 23 01/03/06 3 YA24 23 01/02/06 4 YA24 16 01/02/06 De Lucy Street (5) DS0000036880.V272414.R01.S.doc Version 5.0 Page 22 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA14 YA29 Good Practice Recommendations Continued efforts should be maintained to recruit permanent staff able to drive the vehicle provided for service users. One service user should have an OT assessment to determine whether access to the vehicle can be achieved safely. De Lucy Street (5) DS0000036880.V272414.R01.S.doc Version 5.0 Page 23 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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