Inspection on 10/02/06 for Egmont Road (33)

This inspection was carried out on 10th February 2006.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Egmont Road (33) 27/09/07

Egmont Road (33) 28/09/06

Egmont Road (33) 16/12/05

Egmont Road (33) 14/02/05

Egmont Road (33) 15/07/04

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 Egmont Road (33) 33 Egmont Road Sutton Surrey SM2 5JR Lead Inspector David Pennells Unannounced Inspection 10th February 2006 10:30a Egmont Road (33) DS0000046264.V283028.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 Egmont Road (33) DS0000046264.V283028.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. Egmont Road (33) DS0000046264.V283028.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Egmont Road (33) Address 33 Egmont Road Sutton Surrey SM2 5JR 020 8642 6890 020 8642 8271 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) www.caremanagementgroup.com Care Management Group Limited Mr Mohamed Ismael-Poo Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Egmont Road (33) DS0000046264.V283028.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th December 2005 Brief Description of the Service: 33, Egmont Road is owned, managed and staffed by the Care Management Group (CMG). This residential care home was opened in 2003 and is registered with the Commission for Social Care Inspection to provide care for up to six adults with learning disabilities with associated behaviours of a challenging nature. The home itself is a large semi-detached Edwardian building excellently situated in a suburban area of Sutton - close to local shops, transport links and other amenities that are available, nearby, in the main town centre. There is parking for two cars on the front driveway, and free parking in the street. Accommodation within the home comprises: six single occupancy bedrooms; (one of which has an ensuite toilet and bath, the remaining having toilets and showers), a kitchen, a separate dining room, a comfortable living room, a laundry and an office. There is an additional bathroom for communal use, and toilets situated on both the ground floor and upper floor to meet service users’ and staff members’ needs. All areas are attractively, brightly decorated and furnished in a modern, contemporary style. There is a garden – grassed - at the rear, with an upper level open-air patio. Egmont Road (33) DS0000046264.V283028.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection visit was conducted on a weekday morning, with the inspector meeting the majority of service users, some of the staff, and the manager of the house during his morning stay. The purpose of the visit was to assess any progress made in addressing the relatively few requirements set at the inspection visit of December 2005 and to check that the conduct of the home was continuing to provide a good level of care. Another reason for this visit was that the registered manager - Mr Mohamed Ismael-Poo - had declared his intention to resign his post at the end of December 2005. Obviously the inspector would wish to confirm the upkeep of standards in the absence of a staff member in such a pivotal role. Fortunately for the home, the registered manager had agreed to temporarily stay on, first for a month - and subsequently for another - to support the house whilst the recruitment process for a new manager was undertaken. It was thus expected that, by the end of the month of February 2006, Mr IsmaelPoo would have permanently left the house. It has now been notified to the Commission - subsequent to the inspection visit, but before the dispatch of the draft report - that the manager has agreed to remain in post permanently at the home. This will be of great benefit generally - ensuring continuity for service users and staff, and ongoing management direction for the home. What the service does well: 33, Egmont Road provides a service to clients who have challenging behaviour and, as ever, the inspector was impressed by the focus and dedication of the staff team working with these service users. The culture of the house ensures that each service user is regarded personally - and the plans of care and intervention are well formed, reflecting closely the needs of that specific individual person. The home is a pleasant and bright environment, providing a homely environment for service users who use the space and facilities very well. The service generally continues to run at a very high level of professionalism and focus; the manager and staff (forming a [once again] stable and reliable staff team) are again commended for the service they maintain. The retention of the services of the present manager is clearly going to return the benefits of stability and focus of the service to the home. This consistent and supportive input, since the inception of the home over the past three years, will hopefully allow the service to flourish with renewed attention. Egmont Road (33) DS0000046264.V283028.R01.S.doc Version 5.1 Page 6 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. Egmont Road (33) DS0000046264.V283028.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Egmont Road (33) DS0000046264.V283028.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): none fully inspected at this visit. The home provides a comprehensive Statement of Purpose and Service User Guide which ensures that all necessary information about the service is available both for service users and others enquiring about the home. Prospective service users can be confident that they will have the opportunity to find out about the home, to visit (including staying for short periods) and – through adequate assessment and consultation - be assured that the home can meet their needs prior to making a firm decision to stay. Service users will receive a contract [in a communication strategy suited to their needs] - and this ensures that all ‘terms and conditions’ are known and recognised from the point of confirmation of the contract. EVIDENCE: The key standard - and others - were inspected at the visit in December 2005 and found ‘met’. Nothing significant had changed at the home within these last two months, and therefore the above reiterates the judgement statements made at that time. Egmont Road (33) DS0000046264.V283028.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): none fully inspected at this visit. The home maintains care plans and assessment documents designed to ensure that the needs of service users are met in a focused and individual way, with their rights to individuality and self-expression being protected, and the wishes and aspirations of the service user being taken into account. Service users can be assured that risk-taking will be an integral part of the support / protection plans put in place by the home. EVIDENCE: The key standards were inspected at the visit in December 2005 and found ‘met’. Nothing significant had changed at the home within the last two months since that visit, and therefore the above reiterates the judgement statements made at that time. Egmont Road (33) DS0000046264.V283028.R01.S.doc Version 5.1 Page 10 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): none fully inspected at this visit. Service users can be assured that the service provides opportunities for them to engage in activities both within and outside the home – using local community resources, and to adopt a lifestyle best suited to the individual. Relatives / friends can expect a positive welcome from the home, within the context of respect for a service user’s own choices and decision-making. Links with ‘home’ are encouraged to ensure that support from this source and external contacts remain. Service users can expect to be provided with a good standard of nutritious and wholesome food – meeting individual dietary needs and ensuring that mealtimes are a pleasant and enjoyable time. EVIDENCE: The key standards were inspected at the visit in December 2005 and found ‘met’. Nothing significant had changed at the home within the last two months since that visit, and therefore the above reiterates the judgement statements made at that time. Egmont Road (33) DS0000046264.V283028.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): none fully inspected at this inspection visit. Service users can be assured that their personal, health care and emotional needs will be recognised and met by the home’s assessment and care planning programme, with appropriate external support being accessed as appropriate. The systems adopted by the home regarding medication ensure the safety and consistent treatment and support for each service user. The systems and relationships formed with other professionals ensure a high standard of input in this regard. Service users and their relatives /advocates can be assured that they will be supported through any level of possible trauma, the house being well prepared to face and confront eventualities, including the (currently unlikely) death of a service user. EVIDENCE: All the standards including the key standards were inspected at the visit in December 2005 and found ‘met’. Nothing significant had changed at the home within these last two months, and therefore the above paragraphs reiterate the judgement statements made at that time. Egmont Road (33) DS0000046264.V283028.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): 23. Service users and their advocates can be assured that their comments or complaints will be taken notice of, investigated and acted upon within the home’s stated procedural timescale. The home provides support to service users to ensure that they are protected from harm and any form of abuse, however the policy and procedure relating to investigating allegations of abuse and dealing with vulnerable adults does not blend in with the local authority procedure adequately – thus putting service users at possible risk of mishandling of such situations. EVIDENCE: The first paragraph above states the last inspection’s assessment finding that the home’s complaints process continues to be satisfactorily met. The second standard originally contained a ‘strong recommendation’ - but now carries a requirement - that the registered provider take steps to ‘tie in’ the CMG Adult Abuse policy with that of the host local authority (London Borough of Sutton revised 2005 version). This remains to be achieved, and the inspector remains concerned that the two policies continue not to concur. The ‘current’ CMG policy (April 2002) does not cover immediately reporting the issue directly to the local social services care management team – a protocol that is now established with all care providers within the Borough (and common to other Boroughs too). The majority of the staff team have undertaken training on ‘Vulnerable Adults’ – and some have been involved with adult protection issues relating to service users within the home. However, the possibility of confusion - and therefore potential delay of correct reporting and seeking advice in such incidents - could put service users at possible risk from mis-management of such a situation if, & when, it arises. Egmont Road (33) DS0000046264.V283028.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 & 27. Service users may expect the home to be a generally safe, clean and a pleasant & comfortable environment to live in, though attention to the issues regarding heating and the top floor bathroom must be addressed. Private space meets the needs of the individual service user well, and promotes the concept of privacy and the chance to express their own character through content, furnishings and decoration. EVIDENCE: The heating issues at no 33 still is yet to be properly resolved; the control of the heating supply from next door (no 31) is unsatisfactory; additional heating units (not free-standing), or an override mechanism - must be introduced into the home, to enable proper local control of the temperature. It was understood that a survey of the heating provision was due to be undertaken on 17/02/06. The communal toilet and bathing facilities are additional to the en-suites provided in each of the service user’s bedrooms. The top floor bathroom – though not frequently used (and generally locked) - must have the extractor fan restored to working order, and the radiator panel covered for safety. The home continues to be kept very clean - and free from odours. Egmont Road (33) DS0000046264.V283028.R01.S.doc Version 5.1 Page 14 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): 31 & 36. Service users can rely on the home providing adequate staff in sufficient numbers and duly competent to provide a service that seeks to generally meet identified needs, though basic NVQ skills levels are yet to be achieved. The home’s recruitment and staff support mechanisms are organised so as to ensure the safety, protection and wellbeing of service users. Staff members are well supported through management oversight on a day-today basis, but the need for regular professional supervision input is identified and would be beneficial to encourage a personal and specialised approach. EVIDENCE: A minimum of 50 of the care staff team must be qualified - nominally - to NVQ Level 2 in Care; the timescale to meet this proportion was the end of December 2005. The organisation has shown a commitment to ensure current trainees are qualified and will then open the training opportunity to more staff. Formal staff supervision processes at the home suffered the set back of the prospect of the manager leaving and this requirement being left to the new manager. With the manager now remaining, this requirement is now to be urgently met. Both the manager and deputy have received supervision training and it is hoped that the formal process can soon be properly put in place, with regular input to all staff members. Egmont Road (33) DS0000046264.V283028.R01.S.doc Version 5.1 Page 15 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): none were fully inspected at this visit. Service users and their relatives / friends can rely on the home being run well, and providing a professional service with the best interests of the service user being central to the care provision. The registered providers can be relied upon to seek opinions and comments about the service from both service users and their advocates. The home will take seriously and act upon issues raised for their attention. Health & safety issues are properly addressed and heeded – to the benefit and for the safety of those residing at the home. EVIDENCE: Since this inspection visit took place, the Commission has been notified (prior to the dispatch of this report in draft) that the manager - who was intending to leave - has agreed to remain in post permanently at the home. This will be of great benefit generally - ensuring continuity for service users and staff, and ongoing management direction for the home. Egmont Road (33) DS0000046264.V283028.R01.S.doc Version 5.1 Page 16 All aspects of the key standards were assessed at the previous visit and found ‘met’. The inspector therefore only focused on essential health & safety issues at this visit. Previous inspections had shown the other standards also to be satisfactorily ‘met’. The inspector reviewed all essential health & safety issues at this inspection visit (fire / temperature checks /accident & incident records / etc.) and all were found to be in order. Excepting the need to address extraction and radiator covering issues in the top ‘hip-bath’ bathroom on the top floor (rarely used), no outstanding premises issues were in evidence at this inspection visit; all maintenance, servicing and safety checks were again well recorded, and adequate to the home’s safety and conduct. Egmont Road (33) DS0000046264.V283028.R01.S.doc Version 5.1 Page 17 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 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 2 28 X 29 X 30 X STAFFING Standard No Score 31 2 32 X 33 X 34 X 35 X 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X X X X X X X X Egmont Road (33) DS0000046264.V283028.R01.S.doc Version 5.1 Page 18 Are there any outstanding requirements from the last inspection? YES 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 YA23 Regulation 13(6) Requirement The registered provider’s policy with regard to adult abuse must be amended to accurately tie in the approach required locally under the jointly agreed (and newly-revised 2005) London Borough of Sutton Vulnerable Adults Procedure Guidelines. Timescale of 28/02/06 yet to be exceeded. Timescale for action 28/02/06 2. YA24 23(2)(p) The heating issues at no 33 must 28/02/06 be resolved; the control of the heating supply from No 31 is unsatisfactory, additional heating units (not free-standing) - or an override mechanism - must be introduced to enable local control of the home’s temperature. Timescale of 30.07.05 not met - & of 28/02/06 not yet exceeded. The top floor bathroom must have the extractor restored to working order & the radiator panel covered to maximise safety precautions at the home. Timescale of 28/02/06 not yet exceeded. DS0000046264.V283028.R01.S.doc 3. YA27 13(4) & 23(2) 28/02/06 Egmont Road (33) Version 5.1 Page 19 4. YA31 18(1) A minimum of 50 of the care staff team must be qualified nominally to NVQ Level 2 - in Care (31). Previously a target which deadline of 31/12/05 has now been exceeded. 30/06/06 5. YA36 18(2) Staff must be offered regular, 31/03/06 formal, individual staff supervision as soon as practicable, once the senior staff members have been suitable trained (36). Timescales of 30.10.04, 30.06.05 & 28/02/06 not due to be met. 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 Egmont Road (33) DS0000046264.V283028.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Egmont Road (33) DS0000046264.V283028.R01.S.doc Version 5.1 Page 21 - 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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