Inspection on 02/02/06 for Dove, The

This inspection was carried out on 2nd February 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Dove, The 31/10/06

Dove, The 27/09/05

Dove, The 03/03/05

Dove, The 11/10/04

Dove, The 08/03/04

Dove, The 11/11/03

Dove, The 17/06/02

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

CARE HOME ADULTS 18-65 Dove, The 36, South Croxted Road London SE21 8BB Lead Inspector Ms Alison Pritchard Unannounced Inspection 2 February 2006 3.45pm nd DS0000007095.V277278.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 DS0000007095.V277278.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. DS0000007095.V277278.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Dove, The Address 36, South Croxted Road London SE21 8BB 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) 020 8761 4143 thedove@btopenworld.cpm L`Arche Lambeth Care Home 3 Category(ies) of Learning disability (0), Learning disability over registration, with number 65 years of age (0) of places DS0000007095.V277278.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 3 People with learning disabilities, one of whom may be over 65. Date of last inspection 27th September 2005 Brief Description of the Service: The Dove is a large semi detached Edwardian house located on a residential road in West Dulwich, South East London. It provides care and accommodation for up to three service users with learning disabilities and three members of staff. Service users’ accommodation is located on the ground and the first floor. The Dove is one of six homes owned by L’Arche Lambeth, part of the national organisation, whose communities are based round small scale, everyday housing within local neighbourhoods. Public transport is available outside. It is located close to local shops, restaurants and a large park. DS0000007095.V277278.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 carried out in the late afternoon and early evening of a day in early February 2006. The inspector had the opportunity to talk to one resident, observe care practice, tour the premises, discuss issues with the manager and examine a range of records. The inspection was facilitated by the manager and residents who were welcoming and courteous. What the service does well: What has improved since the last inspection? 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. DS0000007095.V277278.R01.S.doc Version 5.1 Page 6 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 DS0000007095.V277278.R01.S.doc Version 5.1 Page 7 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): 5 A statement of terms and conditions confirms residents’ occupancy of the home and the services they receive. EVIDENCE: The file of one of the service users contained an occupancy agreement that met the requirements of standard 5. Standards 2,3 and 4 were met at the last inspection of the home in September 2005. DS0000007095.V277278.R01.S.doc Version 5.1 Page 8 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 Residents benefit from the care planning system which provides staff with the information they need to satisfactorily meet residents’ needs. Residents and their advocates contribute to the care plans and review system. Risk assessments need review to ensure their current relevance. EVIDENCE: Care plans were examined and were found to cover the range of the residents’ needs. One of the plans was reviewed in November 2005 and the other in January 2006. The reviews included the involvement of the residents, staff from the home and other people of importance to the residents, ho know them well and are concerned for their interests. The files showed that the home and the organisation generally has taken notice of residents’ expressed preferences about their living situations and are making plans to ensure that the arrangements suit their needs. Risk monitoring forms were seen on the files. Although they covered an appropriate range of activities one was dated February 2004 and the other September 2004. The documents need to be reviewed to assess if they are still relevant or need amendment. DS0000007095.V277278.R01.S.doc Version 5.1 Page 9 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): 11, 12, 13, 14, 15, 17 Residents benefit from a range of leisure opportunities which reflect their needs and interests and enable community involvement. Residents have friendships with people outside of the home and are supported to make and receive visits. The meals provided in the home are enjoyed by residents and meet their nutritional needs. EVIDENCE: On the day of the inspection one of the residents had been out in the afternoon with a member of staff. They had been to a café for a drink and something to eat. On three days a week this resident attends a ‘relaxing’ group which is organised by L’Arche Lambeth. The resident told the inspector that while at home she likes to knit and there was a note in the minutes of her review meeting that she enjoys using the home’s computer. The other resident attends a gardening group and a weaving workshop during the week. At home she sometimes likes to play music. This level of activity is appropriate for the residents’ needs. DS0000007095.V277278.R01.S.doc Version 5.1 Page 10 A resident informed the inspector that they had enjoyed Christmas and that they had visited friends in another L’Arche Lambeth home for their celebratory lunch. During the inspection residents were visited by a friend who comes to the home for dinner each week. The way in which the residents are supported to maintain their friendships is a particular strength of the organisation. One of the residents assisted the manager to prepare a fruit salad for the evening meal. The menu records for the last week showed that a range of food is prepared, including fresh fruit and vegetables and that residents have the opportunity to eat with friends and in local cafes and restaurants. A resident confirmed that generally she likes the food. DS0000007095.V277278.R01.S.doc Version 5.1 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 The health needs of service users are well met with evidence of good multidisciplinary working which has benefited residents. The medication is well managed. EVIDENCE: A care plan examined included reference to the need to be aware of the resident’s dignity while assisting with personal care tasks. Interaction seen between the manager and residents was respectful and patient. Records showed that residents’ health care needs are met by attendance at appointments, monitoring health conditions. Notes in files showed that there is a proactive approach to health care so that concerns are followed up and raised with professionals for further investigation. A letter on a file showed that there is awareness of residents’ emotional needs and care taken to ensure that they are met. The medication administration records were in good order. The homely remedies for one resident had not been reviewed since May 2004. The manager assured the inspector that an appointment with the GP had been made for the following week so that this could be followed up. DS0000007095.V277278.R01.S.doc Version 5.1 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 The complaints and adult abuse procedures contribute to the protection of residents. EVIDENCE: There have been no complaints made about the home since the last inspection in September 2005. The residents are aware of how to raise a concern and a poster which uses pictures to describe the complaints procedure is displayed in the hallway of the home. Abuse awareness training is part of the L’Arche induction and foundation training undertaken by all staff in their first year of employment. The adult protection policy of the managing organisation is suitable for its purpose. There have been no investigations carried out under the adult protection procedures in the last year. DS0000007095.V277278.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 30 Overall the building is clean, comfortable and homely but planned redecoration and replacement of a carpet will improve the appearance of the building. There were some matters which needed attention to ensure that residents are safe. EVIDENCE: A tour of the building showed that the home is comfortable and homely. Redecoration of the home is scheduled to begin in May 2006 and this will improve the appearance of some areas of the home. It is also planned that the hall and stair carpet will be replaced. Issues raised at the last inspection of the home have been addressed – specifically all of the rooms are now fitted with locks, curtains have been replaced and new bedding has been purchased. A resident confirmed that she had chosen the bedding and said that she was pleased with it. However three problems were identified as needing attention, these were: 1. the door of the first floor bathroom had a bolt at the top of the inside of the door which could not be opened from the outside in an emergency. 2. the smallest bedroom on the first floor (currently unused) had the sash window opened wide and the window locks had been removed. This left DS0000007095.V277278.R01.S.doc Version 5.1 Page 14 the home vulnerable to intruders and could have presented risks to residents. 3. a damaged piece of carpet on the first floor landing could have been a trip hazard. The manager agreed to ensure that these matters were dealt with and ensured that the window locks were re-fitted during the inspection. The residents have personalised their bedrooms, they are comfortable and suitable for their needs. Communal space consists of a living room a dining room and conservatory which is used as a smoking room. The home was clean and hygienic at the time of the inspection. DS0000007095.V277278.R01.S.doc Version 5.1 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): 32, 33, 35 Although the staff team has vacancies, care is taken to ensure that temporary staff are familiar with the needs of the residents. The residents benefit from staff who have been on courses relevant to their particular needs. EVIDENCE: Since the last inspection the previously registered manager has left his post, as has a member of the care staff. At the time of the inspection another member of the care staff team was on holiday. The gaps in the rota are filled by the newly appointed manager of the home, a member of the bank staff team and agency staff. The bank worker was previously the manager of the home and the newly appointed manager of the home was previously a member of care staff so both are familiar to the residents and with their needs. Agency staff are given an induction to the home and residents’ views are sought on their suitability for work at the home. The rota showed that there is one member of staff on duty at all times. At nighttime there is one member of staff awake in the home and another asleep in the building and available as necessary. These numbers are appropriate for the needs of the residents. The rota needs to be amended so that the member of staff providing waking night duty is shown. DS0000007095.V277278.R01.S.doc Version 5.1 Page 16 The home has a training plan, which covers the appropriate range of issues to ensure that staff have the appropriate skills for their work in the home. staff had recently undertaken training which should assist them in helping one of the residents with issues around communication. The last inspection report commented on the recruitment procedures which needed to be strengthened. Since then the organisation has worked to make their practice in this area more robust. Recruitment records will be checked by the CSCI in the next inspection year. DS0000007095.V277278.R01.S.doc Version 5.1 Page 17 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, 39, 42 Suitable management arrangements have been made since the previously registered manager left his post. Residents have the opportunity to raise issues of concern at visits to the home by senior members of the organisation. The residents and staff are protected by regular health and safety checks, but some issues which may have presented risks had not been addressed in the checks. EVIDENCE: As noted above the previously registered manager has left his post but continues to work at the home through the staff bank. A new appointment has been made to the post of manager. As the new post holder was previously a member of the care staff team she is very familiar with the residents, staff and the running of the home. The inspector was informed that an application for the registration of the manager of the home under the Care Standards Act is to be submitted but it has not yet been received. DS0000007095.V277278.R01.S.doc Version 5.1 Page 18 Visits to the home are made regularly by members of the managing organisation. Arrangements have been made to ensure that if the usual visitor is unavailable that someone else makes the visit in their place. There is a fire risk assessment in place which is dated May 2005. Weekly health and safety checks are conducted covering a range of safety issues including fire checks, food hygiene and other hazards, additional matters are checked each month. However three issues raised above at standard 24 compromised residents’ safety, these matters must be included in the weekly checks of the building. On 9th January 2006 the fire systems were checked and found to be effective. DS0000007095.V277278.R01.S.doc Version 5.1 Page 19 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 x 3 x 4 x 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 x 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 x 2 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 4 16 x 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 2 x DS0000007095.V277278.R01.S.doc Version 5.1 Page 20 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 YA9 Regulation 13(4)(c) Timescale for action The Registered Person must 01/05/06 ensure that risk assessments are reviewed to ensure that they are currently relevant for the residents. The Registered Person must 01/05/06 confirm that the following matters have been addressed to ensure residents’ safety: • window locks must not be removed • the bolt on the top of the door of the bathroom (1st floor) must be removed • the carpet on the landing must be made safe Requirement 2 YA24YA42 13(4)(a) 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 DS0000007095.V277278.R01.S.doc Version 5.1 Page 21 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 DS0000007095.V277278.R01.S.doc Version 5.1 Page 22 - 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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