Inspection on 25/01/07 for El Shaddai

This inspection was carried out on 25th January 2007.

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 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

El Shaddai 27/02/06

El Shaddai 29/09/05

El Shaddai 28/02/05

El Shaddai 07/09/04

El Shaddai 11/11/03

El Shaddai 25/08/03

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Edenvale

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Chatsworth Care - Dawson House

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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 El Shaddai 17 Octavia Close Mitcham Surrey CR4 4BY Lead Inspector Liz O`Reilly Unannounced Inspection 25th January 2007 02:30 El Shaddai DS0000027245.V328575.R01.S.doc Version 5.2 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 El Shaddai DS0000027245.V328575.R01.S.doc Version 5.2 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. El Shaddai DS0000027245.V328575.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service El Shaddai Address 17 Octavia Close Mitcham Surrey CR4 4BY 0208 646 0159 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) Ms Brenda Willis Post Vacant Care Home 3 Category(ies) of Learning disability (3) registration, with number of places El Shaddai DS0000027245.V328575.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Three Adults (M/F) with Learning Disabilities Date of last inspection 27th February 2006 Brief Description of the Service: El Shaddai is a registered care home for up to three adults with learning disabilities. The home is a three storey town house situated in a residential area of Mitcham, close to local shops, leisure facilities and public transport links. The property is in keeping with neighbouring houses and is not identifiable as a care home. The ground floor of the home consists of a kitchen/dining room and a toilet. The lounge and one bedroom are situated on the first floor with a bathroom and the remaining two residents’ bedrooms on the second floor. Fees for this home are £340.00 per week at the time of this inspection. El Shaddai DS0000027245.V328575.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out by one regulation inspector over one day. We had the opportunity to speak with both residents, the home owner and one other member of staff. Questionnaires were also provided for residents and staff. Judgements are made using information gathered from all of the above sources. 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. The summary of this inspection report can be made available in other formats on request. El Shaddai DS0000027245.V328575.R01.S.doc Version 5.2 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 El Shaddai DS0000027245.V328575.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Admissions are not made to the home until a full needs assessment has been carried out and only then if staff are confident that they can meet the needs of the individual. EVIDENCE: Two residents are living at the home and have done for some years. No new resident has moved in for some time. However, procedures are in place to make sure that a copy of the care management assessments are provided before anyone moves in and the home owner carries out their own assessment. This makes sure that the needs of any new person will be known and can be met. It also makes sure that any new resident will “fit in” with the present residents. Information from the assessments is used to provide an initial care plan. Any restrictions on choice, freedom, services or facilities are discussed and agreed with individual residents and become part of the care plan. El Shaddai DS0000027245.V328575.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported to make their own decisions about their lives. Care plans are compiled in consultation with each individual. Residents are informed of their rights. EVIDENCE: Each person has their own care plan. Residents told us that they had seen their care plan and had signed to say they agreed with what was planned. Care plans are short but cover the social, emotional and physical needs and wishes of each resident and how they will be met. Reviews are carried out on a regular basis to ensure that any changes in needs or wishes are incorporated. As noted in previous inspection reports work should continue to make documents, including care plans more accessible to residents. Residents told us that they make their own decisions about their day to day activities and about the home. Risk assessments are in place and can be adapted to take into consideration any new activity a resident may wish to take part in. El Shaddai DS0000027245.V328575.R01.S.doc Version 5.2 Page 9 Information on advocacy services is provided to residents. A statement of residents rights is on display in the home. Residents said they enjoyed the residents meetings where they could discuss common issues such as the menu. El Shaddai DS0000027245.V328575.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have the opportunity to develop and maintain personal and family relationships. Residents take part in activities which meet their personal needs and wishes. Residents confirmed that they are consulted on and make their own decisions on day to day domestic and leisure activities. EVIDENCE: Residents said they were very happy with the activities they take part in and confirmed they made their own choices about visitors and outings. Both residents attend a local day centre which they each said they enjoyed. Residents confirmed that they can have visitors at any time and can go out to visit their own friends when they wanted. The staff and residents visit an ex resident who has moved to another home. Residents said they enjoyed keeping in touch with this person and inviting them back to visit. El Shaddai DS0000027245.V328575.R01.S.doc Version 5.2 Page 11 Residents said they enjoyed going out on trips together to Brixton market, Oxford Street, shopping in Wimbledon, to church and out for meals. The residents and staff had recently returned from a holiday in Florida. Both residents said they had “really liked” the holiday and had a “great” time. One resident was able to meet up with a relative while there. Residents said they kept their own rooms tidy and sometimes helped with the washing up and shopping for the home. Discussions on the meals take place during regular resident and staff meetings. Residents said they liked the food and that they were given meals that they had chosen. El Shaddai DS0000027245.V328575.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 & 21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported by staff to remain independent and responsible for their own personal care. Staff support residents to attend regular health care appointments. Residents are encouraged to take responsibility for their own medication. EVIDENCE: Residents told us that they attended regular health care appointments and staff reminded them and accompanied them to check ups if they wished. Residents are registered with a local GP practice and also attend a local “well women” clinic. The staff working at the home have health care qualifications and so are well informed on the health needs of individuals. Neither of the two residents require assistance with their personal care. Residents have been given the opportunity to discuss with staff what they would like to happen should they get a terminal illness or die. Their wishes have been recorded so that staff are aware of what each person wants. Staff were also supporting one resident to deal with the death of a very close relative. One person is supported to look after and administer their own medication. Records are kept of all medication coming into and going out of the home. El Shaddai DS0000027245.V328575.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are well informed on the complaints procedure and staff receive training on the protection of vulnerable adults. EVIDENCE: Residents are well informed of their right to make a complaint about the home. Neither of the two residents felt that they had anything to complain about. We found that residents were confident that the home owner would “sort out” any problems or concerns they might have. Residents said that if the owner could not help them they would either go to their family or speak to people at their day centre. Information on what to do if residents are not happy with things is available on display in the home in an easily read format. The staff attend training sessions outside the home on the protection of vulnerable adults. This makes sure that residents are supported by staff who have a good understanding of protecting people from abuse and what to do if they have any concerns. El Shaddai DS0000027245.V328575.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with a comfortable, homely environment. EVIDENCE: The building is a town house in a residential area and is not identifiable as a care home. Residents have access to a large kitchen dining room on the ground floor and a comfortable lounge on the first floor. Bedrooms are on the first and second floor. Residents told us that they were “very happy” with their own bedrooms. One resident said they had recently changed their bedroom and they preferred the room they now had. Bedrooms are personalised and reflect the interests and activities of each individual. Residents have added their own ornaments, pictures and photographs. At the time of the last inspection requirements were made for certain repairs to be done. These have been completed. All areas of the home were in a good state of repair, clean and tidy. El Shaddai DS0000027245.V328575.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have confidence in the staff that care for them. Training opportunities are available. The recruitment procedures are followed which assists in making sure that residents are protected. Communication between staff is good. EVIDENCE: As there are only two residents there is a very small staff group. We observed good interactions between the two staff on duty and the residents. Residents made very positive comments about the staff. The owner was described as “lovely” and “very nice”. In order to protect residents, appropriate checks are carried out on staff before they start work in the home. These checks include written references and criminal records bureau checks. Staff have taken part in training on adult protection and mental health issues. On the day following the visit staff were taking part in a food hygiene course. Staff take advantage of the local authority training courses on offer. El Shaddai DS0000027245.V328575.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents felt they were listened to by the home owner and staff and that their views were taken into account. Staff carry out checks to ensure the health and safety of residents and visitors to the home. EVIDENCE: The owner, who has significant experience, also manages the home. Residents told us that they had a good relationship with the manager and felt confident that they were listened to. An annual review of the care provided has been carried out and included getting the views of residents and other people involved with the home. This, along with regular residents meetings, ensures that residents have opportunities to give their opinions and influence how the home is run. The home owner reported that action had been taken to comply with the requirements made by the fire authority and that they had been back to the home to check the work. At the time of the last inspection a requirement was made for the home owner to confirm in writing that these requirements had El Shaddai DS0000027245.V328575.R01.S.doc Version 5.2 Page 17 been met to the satisfaction of the fire authority. We have not received this written confirmation and so this requirement remains outstanding. Regular checks are carried out and recorded to make sure that the health and safety of residents, staff and visitors are protected. El Shaddai DS0000027245.V328575.R01.S.doc Version 5.2 Page 18 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 3 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 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 X 3 X X 2 X El Shaddai DS0000027245.V328575.R01.S.doc Version 5.2 Page 19 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. 3. Standard YA24 Regulation 23(4) Requirement The Registered Persons must provide written confirmation to the CSCI that the requirements made by the London Fire and Emergency Planning Authority have been complied with. Timescale of 01/05/06 not met Timescale for action 01/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 Good Practice Recommendations The Registered Person should ensure that residents are provided with up to date information, in an accessible format, about key policies and procedures including care plans. El Shaddai DS0000027245.V328575.R01.S.doc Version 5.2 Page 20 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 El Shaddai DS0000027245.V328575.R01.S.doc Version 5.2 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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