Inspection on 01/09/05 for Dorrien Walk, 25

This inspection was carried out on 1st September 2005.

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

The inspector found 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

Dorrien Walk, 25 10/11/06

Dorrien Walk, 25 26/01/06

Dorrien Walk, 25 12/01/05

Dorrien Walk, 25 12/05/04

Dorrien Walk, 25 16/02/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

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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 Dorrien Walk, 25 25 Dorrien Walk Drewstead Road London SW16 1AR Lead Inspector Lynne Field Unannounced Inspection 1st September 2005 10:00 DS0000022793.V251542.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 DS0000022793.V251542.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. DS0000022793.V251542.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Dorrien Walk, 25 Address 25 Dorrien Walk Drewstead Road London SW16 1AR 020 8677 0414 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) Choice Support John Evans Care Home 2 Category(ies) of Learning disability (2) registration, with number of places DS0000022793.V251542.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th January 2005 Brief Description of the Service: Dorrien Walk is a small, two bedroom, one-storey home on an estate off Drewstead Road. The home is managed by Choice Support Southwark, a large provider of services for people with learning disabilities. The home is registered for 2 adults who have profound multiple disabilities with learning disabilities. This service was set up in 1997 and provides long-term care for the two service users who moved there from long-term accommodation. Dorrien Walk has a small back garden. The home is a tenminute walk from the high street. However, access into some of the shops of interest has proved difficult for people with disabilities. DS0000022793.V251542.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and was carried out on the 1st September 2005. Initially the registered manager was not present but attended the later part of the inspection. The inspector interviewed one member of staff and met both service users. The inspector noted that the midday meal looked tasty and nutritious and that service users enjoyed their meal. The inspection included a tour of the home and examination of records on care plans, staff records and building maintenance records. What the service does well: What has improved since the last inspection? What they could do better: The home needs to look at fire risks and how it can reduce any identified risks to service users and staff. DS0000022793.V251542.R01.S.doc Version 5.0 Page 6 It was noted from records that fire drills were not happening, the registered person must ensure this happens. The garden has been landscaped and flagstones had been laid in order to provide easy access for wheelchairs. However, since the flagstones and gravel have been laid service users have found it difficult to manoeuvre around the garden with ease. 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. DS0000022793.V251542.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 DS0000022793.V251542.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): 1-5 Prospective service users’ needs and aspirations are assessed in such a way that a service tailored to their needs is provided. EVIDENCE: The inspector was shown the statement of purpose and a service users’ guide, which includes the complaints procedure in the service users’ guide. The home’s admissions procedure states: “care management assessments are required for all prospective service user including personal and medical histories before service users are considered”. There have been no recent admissions to the home. Both service users have lived at the home since it opened nine years ago. The registered manager told the inspector if a vacancy arose, the home would follow their procedures outlined in the statement of purpose and service users’ guide and prospective service users would be invited to visit the home with family members or friends to help them decide if the home could meet their needs. The registered manager said the home would then follow this up by completing an assessment based on personal history, care management assessment and a full needs assessment. DS0000022793.V251542.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): 6,7,8,9 Families and professionals are involved when reviews are held. Care plans are thorough and reflect service users’ needs and goals. Service users participation in the running of the home has been encouraged where feasible, such as making a cup of tea or making a cake. Risk assessment reviews take place and are recorded. Staff have easy access to this information which is kept in the homes office. EVIDENCE: Both service user files were inspected. Care plans give a thorough description of service users’ behaviours, reactions and preferences and how the service user was to be treated. Care plans are reviewed six monthly. The inspector viewed individual risk assessments, which had been carried out, monitored and reviewed by the staff with service users every six months or when the need arises. Details of any changes to the risks are recorded in the service users care plans, with details of how to manage the risk. DS0000022793.V251542.R01.S.doc Version 5.0 Page 10 The registered manager showed the inspector the Person Centred Plans for both service users that the home had started to develop for the service users. Communication passports, which give information about each service user in a small booklet, are being developed. The information in them is confidential and would only be used on a need to know basis. DS0000022793.V251542.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): 12,13,14,15,16,17 Service users are able to take part in age, peer and culturally appropriate activities, leisure activities and are part of their local community. They are actively encouraged to develop daily living and social skills. Service users are able to maintain relationships with friends and family. Meals are varied and enjoyed by service users. A healthy diet is provided and mealtimes are relaxed and flexibly timed to fit in with individual activity plans. EVIDENCE: The registered manager told the inspector that service users are supported to make decisions concerning their daily activities. Service users have individual activities programmes, which includes developing independent living skills within the range of the service users abilities. The inspector saw that service users are offered opportunities to participate in the day-to-day running of the home as far as their abilities allow. DS0000022793.V251542.R01.S.doc Version 5.0 Page 12 One service user is able to make herself a cup of tea with staff support and help prepare the vegetables for a meal, again with staff support. Staff said that if the service users do not wish to do an activity they communicate through behaviour. An example given to the Inspector was if one of the service users does not like a meal she is offered she will push the plate away from her. Staff use objects of reference such as one of the service users has a handbag which means she is going out. Both have relatives who are actively involved with the home and act as advocates in decisions relating to social and health care needs of their relatives placed there. Independent advocates are still not involved in Dorrien Walk, a letter was sent to the local advocate to invite them to ongoing reviews and representations but the response was a letter to say at the present time the advocacy service was unable to take on any more service users. A copy of the letter was sent to CSCI and is on file. DS0000022793.V251542.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 Service users receive personal support, in the way they prefer. Medication is being handled safely. EVIDENCE: Care files contain information for staff on service users who need personal support with their preferred personal care routines A key worker system is in operation, with each service user having two members of staff from within the team to co-ordinate their support and care planning. The record of health appointments attended indicated that each service user is supported by staff if this is what the service user requires, to attend an appropriate range of healthcare appointments in line with their individual healthcare needs. Service user medication is stored securely in a locked medication cabinet in the staff office. Staff induction includes medication training and medication administration records. DS0000022793.V251542.R01.S.doc Version 5.0 Page 14 The inspector was told the local pharmacist comes into the home every six months to check the medication and attends a team meeting to give the staff refresher training in medication. DS0000022793.V251542.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 Service user’s are protected by the home’s policies and procedures as well as the safeguards that are in place to protect them from abuse, neglect and selfharm. EVIDENCE: The home has a complaints policy, a copy of which is in the service users’ guide. The vulnerable adults policy of the placing authority is used. There is a copy of the local authorities POVA policy and procedure. From discussions that the Inspector had, staff demonstrated they were aware of gender care policies. A member of staff told the inspector they are aware of abuse and protection policies and how to deal with cases of suspected abuse. Any suspicions are reported to the registered manager to deal with, who will deal with it in an appropriate way following the homes adult protection policies and procedures. The home safeguards service user finances with appropriate recording systems. The inspector was told each service user has a finance book in which all financial transactions are recorded and signed by two members of staff. One service user has their allowance paid directly into their bank. The other service user collects their money, which is then paid into their account. All this is checked and recorded by two staff. Both service users accounts and records were inspected and were found to be in order. DS0000022793.V251542.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): 24,25,26,27,28,29,30 The home is bright, clean, comfortable and safe. Service users rooms are comfortable and are decorated to reflect their personalities. There could be a health and safety risk to the service users with regard to exiting the building in the event of a fire. This must be risk assessed and an action plan put in place to reduce the risk to service users and staff. EVIDENCE: The home is suitable for people with a physical disability as it is all on one level. The service users have lived there for a number of years and although both service users are visually impaired, they can find their way around the home and to their rooms. Dorrien Walk is all on one floor with a ramp up to the front door. All the rooms are easily accessible with wide doors to accommodate wheelchairs. Both service users are visually impaired and are familiar with the layout. The home is comfortable and homely in style. The kitchen has been adapted to meet the DS0000022793.V251542.R01.S.doc Version 5.0 Page 17 present service users’ needs. Worktops are at a level to enable the service users to sit at them and prepare meals with the support of staff, which allows for greater independence. The bedrooms are individual in style and reflect the culture of the service user. The inspector was given a tour of the home and noted that some of the service users possessions were lying on the floor in front of the door to the garden. This could inhibit the service users from exiting by this door should there be a fire. The door to the garden has a step down. It would not be possible for someone in a wheelchair to exit this way. The only exit from the home apart from the front door is through the patio doors from the lounge, which lead to the garden, which is small. Once in the garden it would be impossible for service users to exit the garden. All these issues must be risk assessed and an action plan devised to reduce or eliminate the risk. A requirements has been given about this. Both service users have greatly benefited from the newly refurbished bathroom and hoist, which has allowed them greater independence in bathing. The inspector was told they are often supported to have more than one bath per day. One service user in particular enjoys the garden and the tactile feel of the different textures and the scent of the plants. He had been unable to access the garden, as his wheelchair is not level on the grass. At the last inspection the Inspector had been pleased to note that the garden had been very attractively landscaped and flagstones had been laid to provide easy access for wheel chairs and the shed has been moved. The registered manager reported that although the garden has improved, because of the design and layout of the garden it is still difficult for the service users to move around the garden independently. DS0000022793.V251542.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): 32,33,35,36 Service users individual and joint needs are met by appropriately trained, supported and supervised staff. EVIDENCE: The registered manager reported that staffing levels had improved since the last inspection. This had been the subject of a requirement, which has been met. It was not possible to inspect staff files because they are kept at the organisations head office. These will be inspected by arrangement with the organisation at their head office. The registered manager told the inspector that recruitment includes formal interview, taking up two references, CRB checks and POVA checks prior to appointment and all staff have an employment contract which include details of their terms and conditions of employment. The member of staff the inspector spoke to say they had access to a range of training and confirmed they had recently attended Food Hygiene, Manual Handling, Vulnerable Adults Training, the Role of the key worker and First Aid Training. The home staff team are making good progress in attaining the required percentage of NVQ qualified staff. Staff commented that they feel adequately supported and that they receive frequent supervision from the registered manager. DS0000022793.V251542.R01.S.doc Version 5.0 Page 19 The home’s records show that there have been no referrals under POVA to date. DS0000022793.V251542.R01.S.doc Version 5.0 Page 20 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): 37,38,39,40,41,42,43 The home is being well managed by a manager of good character, long standing experience in care, who is open and supportive in his management approach. There are systems in place to measure the satisfaction of service user and other stakeholders about care provided by the home. Working practices and associated records ensure that the health and safety of service users is promoted. EVIDENCE: Staff said the registered manager is approachable and well respected by staff. Service users families, made it clear that the home is managed in a positive and open way. Staff said they felt they are able to influence the way the home is run via staff meetings and supervision. DS0000022793.V251542.R01.S.doc Version 5.0 Page 21 It was confirmed in the minutes of the staff meetings and through speaking to staff, they feel they are able to influence decisions via supervision and staff meetings. The health, safety and welfare records were checked and while most were in order, there had been no recent fire drills recorded. This must recommence. Regulation 26 visits had been carried out and copies of the reports have been sent to CSCI each month. DS0000022793.V251542.R01.S.doc Version 5.0 Page 22 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 3 3 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 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 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 3 X 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 2 3 DS0000022793.V251542.R01.S.doc Version 5.0 Page 23 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(c)(iii) Requirement The registered persons must make adequate arrangements for reviewing the evacuation arrangements in the event of a fire, of all persons in the care home. The registered person must ensure that fire drills take place at least every six months. Timescale for action 01/01/06 2 YA42 23(4)(e) 01/01/06 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 DS0000022793.V251542.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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 DS0000022793.V251542.R01.S.doc Version 5.0 Page 25 - 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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