Inspection on 27/09/05 for Dove, The

This inspection was carried out on 27th 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 13 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 02/02/06

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 Alison Pritchard Unannounced Inspection 27th September 2005 3:15pm DS0000007095.V253143.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 DS0000007095.V253143.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. DS0000007095.V253143.R01.S.doc Version 5.0 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 L`Arche Lambeth Jacek Drzewinski Care Home 3 Category(ies) of Learning disability (0), Learning disability over registration, with number 65 years of age (0) of places DS0000007095.V253143.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 3 People with learning disabilities, one of whom may be over 65. Date of last inspection 3rd March 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.V253143.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and carried out between 3.15pm and 8pm on a day in late September 2005. The inspector had the opportunity to talk to one resident in depth, observe care practice, tour the premises, discuss issues with the registered manager and examine a range of records. The inspection was facilitated by the registered 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: There were some improvements needed, these concerned making sure that residents’ privacy is protected in the building – by fitting locks to doors and making sure that curtains are replaced when they become detached. Some areas of the building will be improved if there is some more re-decoration. Recruitment must provide service users with a higher degree of protection, by ensuring that adequate checks are taken up for all staff. Some record keeping needs to be improved and an audit of residents’ files is needed. DS0000007095.V253143.R01.S.doc Version 5.0 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. DS0000007095.V253143.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 DS0000007095.V253143.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): 2,3,4 Residents’ benefit from the attention paid to ensuring that admissions to the home are carefully considered. EVIDENCE: There have been no admissions to the home since September 2004. It was found at the inspection of March 2005 that this admission was well managed. The policy of the managing organisation is to consult with the current residents of the home and the potential resident regarding the suitability of any proposed placement. Introductory visits to the home form part of the admission process, as does the consideration of the potential resident’s wishes and aspirations and assessments of need carried out by professionals. DS0000007095.V253143.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, Residents’ benefit from a care planning system, which reflects their ambitions and goals. Some of the documents used as part of care planning need to be reviewed to ensure they are relevant. Residents are consulted about the way that the home operates. EVIDENCE: Each of the residents has a care plan which is reviewed regularly with the involvement of the resident, care staff from the home and L’Arche and other involved friends and advocates as agreed by the resident. One resident had attended a care plan and placement review meeting recently and was able to voice opinions about a range of matters including goals and ambitions. The second resident was due to attend their review in the month after the inspection. Some of the documents seen in a care plan file were in need of review as some were undated and others contained information which was no longer relevant, for example one document called ‘care guidelines’ included reference to an item of medication which had ceased to be used some weeks previously. There were indications that this had not been reviewed for approximately 15 months. DS0000007095.V253143.R01.S.doc Version 5.0 Page 10 Residents are encouraged to express their views about the home and this is part of the ethos of the organisation. To this end each of the residents has an advocate who supports them to voice their opinion. DS0000007095.V253143.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): 11, 12, 13, 14, 15, 16, 17 The residents enjoy a range of activities, which reflect their interests. The residents maintain relationships, which are important to them. The staff in the home are very respectful to the residents, but care needs to be taken that their privacy is fully protected. Although the menu records were incomplete one of the residents said that the meals are good and reflect their choices and preferences. EVIDENCE: The identified goals from a recent care planning review meeting showed that residents are encouraged and supported to maintain and develop skills. Residents are supported to take part in a range of activities in the home and in the community. Some of these activities are arranged through the wider L’Arche community. The residents attend day activities appropriate to their interests and needs. One resident attends workshops at which her creative skills are encouraged and developed. A resident’s file included information about her leisure interests along with details of people who are important to her. During the inspection a friend of the household visited and joined the residents for an evening meal. The residents are also supported to maintain contact with family members and other people of importance to them. DS0000007095.V253143.R01.S.doc Version 5.0 Page 12 The routines of the house promote independence and choice. Respect for each other, privacy and consideration are encouraged in the home. This was apparent in the manner in which staff talk to residents, which is respectful, patient and calm. Permission was sought from residents to show the inspector around the home. One of the resident’s privacy would be further protected by ensuring that a lock is fitted to her bedroom, the lock should be operable from the lockable from the inside and outside but allow access in an emergency. The curtains in this room had been detached from the rail and needed to be refitted as this compromised her privacy. The meals are planned each day in consultation with residents taking account of their likes and dislikes, and their dietary and nutritional needs. Feedback from a resident was that the food is of good quality and reflects their preferences. Residents often assist staff with the preparation of meals. Although the menu was not completed consistently, the available records showed that a range of food is provided which includes fresh items of fruit and vegetables. DS0000007095.V253143.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, 21 A resident expressed satisfaction with the way personal care is provided, but the written guidelines need to be reviewed to ensure their relevance. The home has taken care to meet residents’ health care needs. The managing organisation has taken action to ensure that medication administration is safe and to address areas where errors have occurred. The home has provided very sensitive end of life care for a resident, taking into account the emotional needs and wishes of everyone involved. EVIDENCE: The feedback received was that the care provided is in accordance with residents’ wishes and carried out in a respectful manner. The two current residents are female and the team has a majority of female carers. The personal care guidelines seen in a resident’s file were undated and others were out of date. As noted at standard 6, this needs to be addressed. The residents are supported to attend health care appointments regularly and there were records that showed that follow up action is taken as necessary. The arrangements for medication in the home are to be changed so that blister packs are issued by the pharmacy. The medication is stored safely and the records of administration did not show any gaps. There have been some errors DS0000007095.V253143.R01.S.doc Version 5.0 Page 14 in relation to medication arrangements in the home. These have been reported to the CSCI and the managers have taken appropriate action to ensure that the risk of such errors recurring is reduced. One resident of the home died in the weeks prior to the inspection. The home had extensive liaison with a range of health care professionals involved in the resident’s care with the aim of ensuring that he was supported through his illness and that his wishes and best interests were observed at all times. The process included consideration of the medical and emotional needs of the resident, the other residents of the home and the staff team. The home handled this difficult and sad situation with compassion, sensitivity and care. DS0000007095.V253143.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 Residents are familiar with the complaints procedure. Staff recruitment practices need to be strengthened so that they can contribute to the protection of residents. EVIDENCE: The complaints procedure is displayed in the home and residents are familiar with it. Some concerns raised by a resident are to be dealt with through the complaints procedure. No other complaints have been raised since the last inspection in March 2005. Staff are provided with training is adult abuse issues as part of their induction to the organisation. A check by CSCI in October 2005 of the L’Arche staff recruitment practices found shortcomings in relation to the taking up of Criminal Records Bureau and Protection Of Vulnerable Adults list checks. These procedures have been the subject of extensive discussion with CSCI. Although some improvements have been made the findings of the most recent check did not fully meet the regulation so are subject to a requirement of this report. DS0000007095.V253143.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, 30 The residents benefit from a building, which is comfortable and homely. A programme of redecoration will improve the appearance of some areas of the home. The bedding on one bed was found to be in need of replacement. Residents’ privacy would be further protected by ensuring that locks are fitted to residents’ bedrooms and their safety assured by fitting locks to resident care assistants’ bedrooms. EVIDENCE: The premises are homely and comfortable, and some redecoration has been carried out since the last inspection. Some other areas of the home are still in need of redecoration as the intended programme was appropriately delayed as a result of the ill health of a resident. All areas of the home were viewed during this inspection. Some improvements needed were pointed out to the registered manager. Only one of the residents’ bedrooms was fitted with a lock. These are required to protect residents’ privacy. In addition it was found that resident care assistants did not have lockable bedrooms. This could present a safety risk to residents and the rooms should be locked. As noted above the curtains in one bedroom had been detached from the rail and needed to be re-fitted as this compromised her privacy. The bedding on one bed was found to be in need of replacement. In all DS0000007095.V253143.R01.S.doc Version 5.0 Page 17 other respects the bedrooms were suitable for the current residents’ needs, had been personalised and were comfortable. There is a shower room on the ground floor with a WC and a bathroom with a separate WC on the first floor of the home. The ground floor bedroom has an en-suite WC. The facilities provide sufficient privacy and adaptations suitable for the residents’ needs. There is one large lounge that is used by all of the household. A small conservatory is located off the lounge and overlooks the garden. The dining room which leads off the kitchen is spacious and accommodates a large number of people comfortably for meals. The communal space is suitable for the needs of the home. The home was cleaned to a satisfactory standard at the time of the inspection and there were no offensive odours. The laundry facilities are located at one end of a room, which is also used as an office. As the home is small it is possible to carry out laundry tasks at times when the office is not being used. There is an extractor fan fitted in the room. DS0000007095.V253143.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, 34, 35, Residents are provided with care by enough suitably trained and qualified staff. Staff recruitment practices need to be strengthened so that they can contribute to the protection of residents. EVIDENCE: In addition to the Registered Manager there are three members of staff who work regularly at the home. One of the permanent staff members has NVQ 2, the other has NVQ 3 and the third has a degree in learning disabilities. At the time of the inspection there were two people on duty in the home and a member of staff was to begin a sleeping in shift at 9pm, one member of staff was to begin a waking night shift at 10pm until 7.30am the following morning. These are the usual staffing levels of the home and are suitable for the needs of the residents. The rota was completed in pencil, which is not appropriate as it is a legally required document. Some improvements have been made to recruitment practices however a check by CSCI in October 2005 found shortcomings in relation to the taking up of Criminal Records Bureau and Protection Of Vulnerable Adults list checks. These procedures have been the subject of extensive discussion with CSCI. Although some improvements have been made the findings of the most recent DS0000007095.V253143.R01.S.doc Version 5.0 Page 19 check did not fully meet the regulation so are subject to a requirement of this report. 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. DS0000007095.V253143.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, 41, 42 The residents benefit from a management approach, which is respectful and caring. Residents are encouraged to make their views known to senior representatives of L’Arche when they visit. It is important that these visits are made at a minimum of once a month. In order to contribute to the protection of residents the records must be kept up to date and completed in pen so that they are a permanent record. EVIDENCE: The Manager of the home has been registered under the Care Standards Act by CSCI since October 2004. It is intended that the manager will undertake training to NVQ level 4. The residents and the manager were relaxed and respectful in their conversation and the manager made it possible for residents, who chose to do so, to contribute to the inspection process in privacy. Visits are made to the home by a representative of the managing organisation as required by regulation and as part of the overall monitoring of the service. Reports of these visits are sent to the CSCI and show that there is an DS0000007095.V253143.R01.S.doc Version 5.0 Page 21 appropriate emphasis on ensuring that residents have the opportunity to talk to the visitor. Some visits had been missed as the regular visitor had been unavailable, it is important that when this happens that another representative visits the home. Some records were incomplete and another was only completed in pencil. The manager acknowledged that some administrative activities had received less attention than usual while the home was dealing with the recent illness of a resident. A range of health and safety records were checked and were satisfactory. The London Fire and Emergency Planning Authority (LFEPA) visited the home in June 2005 and were satisfied with the fire prevention and detection arrangements in the home. DS0000007095.V253143.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 x 3 3 3 x Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 3 x x Standard No 24 25 26 27 28 29 30 STAFFING Score 2 2 3 3 3 x 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 2 17 Standard No 31 32 33 34 35 36 Score x 3 3 2 3 x CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 4 Standard No 37 38 39 40 41 42 43 Score 3 3 2 x 2 3 x DS0000007095.V253143.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 YA18YA6 Regulation 15(1) Requirement The Registered Person must ensure that an audit of residents’ files is conducted to ensure documents are reviewed to assess whether they are currently relevant. The Registered Person must ensure that curtains are fitted in residents’ bedrooms and that if they are detached from the rail they are re-fitted without delay in order to protect residents’ privacy. The Registered Person must ensure that the decorating schedule for the home for the next year is sent to the CSCI. The Registered Person must ensure that residents’ safety is protected by fitting locks to the bedroom doors of resident care assistants. The Registered Person must ensure that bedding which is not adequately warm or in an acceptable condition is replaced. The Registered Person must ensure that locks are fitted to all residents’ bedrooms. The locks must be operable from the DS0000007095.V253143.R01.S.doc Timescale for action 01/03/06 2 YA16YA25 12(4)(a) 01/12/05 3 YA24 23(2)(d) 01/01/06 4 YA25 13(4)(c) 15/12/05 5 YA25 16(2)(c) 01/01/06 6 YA16 12(4)(a) 15/12/05 Version 5.0 Page 24 inside and outside but allow access in an emergency. 7 YA17YA41 17(2)(3)(a) The Registered Person must 01/12/05 ensure that records are completed fully and consistently, using a pen rather than a pencil – specifically menu records and rotas. 19(1)(b)(i) The Registered Person must 01/12/05 Sch 2 ensure that evidence of all information and documentation required by Schedule 2 of the Care Homes Regulations 2001 (revised in July 2004) is obtained for staff before they commence work in the care home. 26 The Registered Person must ensure that in the absence of the person who usually conducts visits under regulation 26 that the task is delegated to another representative of the responsible individual. 01/12/06 8 YA34YA23 9 YA39 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.V253143.R01.S.doc Version 5.0 Page 25 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.V253143.R01.S.doc Version 5.0 Page 26 - 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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