Inspection on 27/02/06 for El Shaddai

This inspection was carried out on 27th 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

El Shaddai 25/01/07

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

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 El Shaddai 17 Octavia Close Mitcham Surrey CR4 4BY Lead Inspector Liz O`Reilly Unannounced Inspection 27th February 2006 03:00 El Shaddai DS0000027245.V285902.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 El Shaddai DS0000027245.V285902.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. El Shaddai DS0000027245.V285902.R01.S.doc Version 5.1 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 Care Home 3 Category(ies) of Learning disability (3) registration, with number of places El Shaddai DS0000027245.V285902.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Three Adults (M/F) with Learning Disabilities Date of last inspection 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. El Shaddai DS0000027245.V285902.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by one regulation inspector over two and a half hours on 27th February 2006. The inspector had the opportunity to meet with all three residents and the home owner. Two of the three residents discussed the home with the inspector. A sample of records were also examined. Since the last inspection one new resident has moved into the home. What the service does well: What has improved since the last inspection? What they could do better: Further work needs to be done on the recording of medication to ensure the health and safety of residents. Action needs to be taken to improve the environment in the bathroom. The record of training needs to be improved and staff should be encouraged to take part in NVQ training. The home owner needs to complete an annual review of the service. The home owner must also confirm that the work required by the fire authority has been completed. Documentation including care plans should be produced in a more accessible format for residents. El Shaddai DS0000027245.V285902.R01.S.doc Version 5.1 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. El Shaddai DS0000027245.V285902.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 El Shaddai DS0000027245.V285902.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): 2 Appropriate assessments of the individual needs of residents are carried out before they are admitted to the home. EVIDENCE: All residents had an assessment of their individual needs carried out prior to moving into the home. Staff from the home also carry out their own assessment of the individual. This ensures that the home can meet the needs of each person and that staff are well informed about a new resident before they arrive at the home. Staff use the assessments to set up an initial individual care plan. Any restrictions on choice, freedom, services or facilities are discussed and agreed with individual residents are become part of the care plan. El Shaddai DS0000027245.V285902.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): 6 ,7 &9 Each resident is provided with an individual care plan. Residents confirmed they made decisions about their lives with support from staff if needed. EVIDENCE: Care plans are individualised and cover the physical, social and emotional needs of residents. Reviews were seen to be carried out on a regular basis to ensure that any changes in needs or wishes are incorporated. Good information is available on the particular activities individual residents enjoy. Care plans are signed by staff and residents. As noted in previous inspection reports work should continue to make documents, including care plans more accessible to residents. Individual risk assessments are in place. Residents said they felt they made decisions about their own lives. 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.V285902.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): 12, 14 & 16 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 activity. 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. Two of the three residents attend the same local day centre. One resident attends Merton Mind. Residents said they enjoyed attending the centres and had no wish to look for paid or voluntary employment. Residents explained that they enjoyed going out on trips as a group and helped in planning where they should go. Residents are encouraged to carry on with their individual interests and hobbies. Residents stated they can have visitors to the home at any time and can invite friends to visit them if they wish. One resident said their sister visited them El Shaddai DS0000027245.V285902.R01.S.doc Version 5.1 Page 11 regularly and that they visited their boyfriend in another home on a regular basis. All residents are provided with a key to their bedroom. Residents confirmed that they chose when to be in the company of others or be alone. All residents have unrestricted access to the communal areas of the home. Residents stated that they chose when and if they wished to be involved in domestic tasks around the home. Two residents said they kept their own rooms tidy and sometimes helped with the washing up and shopping for the home. As noted in previous inspection reports the contract in relation to residents holidays do not meet the National Minimum Standards which state that all residents should be offered a minimum seven days holiday as part of the basic contract price. El Shaddai DS0000027245.V285902.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, & 20 Personal care is provided according to residents needs and wishes. Further work needs to be done on the recording of medication. EVIDENCE: Residents confirmed that they were provided with support and advice on personal hygiene by staff. Discussions with residents indicated that staff respect the privacy of each individual. The residents said that they decided when to get up or go to bed except when they had appointments or on day centre days when staff would remind them to get up in time. Residents wear their own clothing and decide on their own appearance. The preferences of residents are well known to staff. Should any resident require nursing input this is provided by community nursing services. Staff monitor the health of residents and seek advice from relevant health care professionals if they have any concerns. At the time of this inspection one resident was being visited by their consultant from the community learning disabilities team. El Shaddai DS0000027245.V285902.R01.S.doc Version 5.1 Page 13 Records regarding medication administered were not clearly recorded. The home owner must review the recording of medication to make sure that:• • • a new medication administration sheet is provided for each month instructions on the dosage and times of medication are written in words details of medication to be taken “as required” include the circumstances in which they should be administered and the maximum dosage El Shaddai DS0000027245.V285902.R01.S.doc Version 5.1 Page 14 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 The registered person has taken appropriate steps to make sure that residents are protected from abuse. EVIDENCE: All staff have been provided with training on the protection of vulnerable adults. The home follows the London Borough of Merton procedures for the protection of residents which ensures that staff are aware of their responsibilities to report any concerns or allegations of abuse to the local authority. Staff are also aware of their responsibilities to also inform the CSCI of any concerns or allegations. Guidance for staff on the protection of residents from abuse was seen to be on display in the kitchen. El Shaddai DS0000027245.V285902.R01.S.doc Version 5.1 Page 15 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, 26, &30 The premises provide a comfortable and homely environment. Certain maintenance issues need to be dealt with. The home owner must confirm in writing that the requirements made by the London Fire and Emergency Planning Authority regarding the home have been complied with. The home was clean and tidy. EVIDENCE: Each resident is provided with their own bedroom. The bedrooms of the two residents who have lived in the home for some time were seen to be personalised, reflecting individual interests and taste. The home owner stated that the belongings of the new resident had not been fully installed at the time of this visit. Furnishings provided are in good condition and of good quality. It was noted that the extractor fan in the bathroom was still not in working order. This has been the case since the last inspection of the home and urgent action is required to repair or replace the extractor. The seal around the bath is in a poor condition and must be replaced. El Shaddai DS0000027245.V285902.R01.S.doc Version 5.1 Page 16 Immediately following this visit to the home the inspector was contacted by an officer from the London Fire and Emergency Planning Authority (LFEPA) who stated that a number of requirements relating to the fire regulations had been made on this home. The home owner must confirm in writing to the CSCI that all requirements made by the LFEPA have been met. The home owner must also contact the LFEPA to confirm that the actions taken are appropriate. El Shaddai DS0000027245.V285902.R01.S.doc Version 5.1 Page 17 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 The home has a very small staff team who residents expressed confidence in. The record of staff training needs to evidence all staff being provided with five paid days training each year. Sufficient staff are available to meet the present needs of the resident group. EVIDENCE: Staff were observed to be comfortable with and communicate well with residents. Residents gave very positive comments on the approach of staff. All staff are over the age of 21 and agency staff are not used in this home. This ensures residents are supported by people they are familiar with and well informed on individual needs. Staff meetings are held on a regular basis. Which ensures that all staff are kept informed of any changes and provides an opportunity to discuss practice issues. None of the present staff group have completed NVQ training as yet. The registered person informed the inspector that one member of staff was considering commencing this training. One member of staff is available at all times when residents are in the home. At night one member of staff sleeps on the premises. These staffing levels are El Shaddai DS0000027245.V285902.R01.S.doc Version 5.1 Page 18 sufficient to meet the needs of the present resident group. Should the needs of any resident increase these staffing levels will need to be reviewed. The home produces a staff training programme. The programme for the last year included fire awareness, challenging behaviour, understanding autism and the protection of vulnerable adults. One member of staff has not completed training in food hygiene. Arrangements must be made for this member of staff is supplied with this training. The home owner must ensure that a record of staff training is kept for each member of staff which provides evidence of five paid days training each year. El Shaddai DS0000027245.V285902.R01.S.doc Version 5.1 Page 19 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 The home does not have a registered manager at present. Further work needs to be done to carry out an annual review of the service. Staff carry out checks on the home to ensure the safety of residents, staff and visitors. EVIDENCE: At the time of this inspection the managers post in the home was vacant. The home owner was also managing the service. Plans are in place for a manager to be appointed in the future. The home owner has devised a questionnaire to be used as part of the monitoring of the quality of care in the home. However an annual review of the service has not been carried out. A review must be carried out on an annual basis with a copy of the report produced provided to the CSCI. Records showed staff check smoke detectors and the temperature of hot water on a weekly basis. Information on cleaning materials is available to ensure El Shaddai DS0000027245.V285902.R01.S.doc Version 5.1 Page 20 they are used correctly and to be used in the event of any accident. Fixed electrical equipment is checked every five years. A record of any accident is kept along with details of the incident and outcomes. As noted previously the home owner must confirm requirements made by the fire authority have been complied with. El Shaddai DS0000027245.V285902.R01.S.doc Version 5.1 Page 21 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 x 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 3 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 2 33 2 34 x 35 2 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 x 14 2 15 x 16 3 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 x 2 x 2 x 2 x x 2 x El Shaddai DS0000027245.V285902.R01.S.doc Version 5.1 Page 22 Yes 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 YA20 Regulation 13(2) The Registered Person must review the recording of medication to make sure that:• • • • • a new medication administration sheet is provided for each month. instructions on the dosage and times of medication are written in words. details of medication to be taken “as required” include the circumstances in which they should be administered and the maximum dosage. 01/05/06 The Registered Person must ensure that the extractor fan in the bathroom is repaired or replaced. The seal around the bath must be replaced. Requirement Timescale for action 01/05/06 2. YA24 23(2)(b) El Shaddai DS0000027245.V285902.R01.S.doc Version 5.1 Page 23 3. YA24 23(4) 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. 01/05/06 4. YA32YA35 18(1)(c ) 5. YA39 24(1)(2) The Registered Person must contact the London Fire and Emergency Planning Authority to confirm that the actions taken are appropriate. The Registered Person must 01/05/06 ensure that the record of training shows each member of staff being provided with a minimum of five paid days training each year. The Registered Person must 01/06/06 ensure that a regular review of the service provided is carried out. A copy of the report produced following such review must be provided to the Commission. Timescale of 10/01/06 not 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. 1. Refer to Standard YA8 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. Staff should be encouraged to take part in NVQ training in order for the home to meet the National Minimum Standards. The Registered Person should ensure that residents have DS0000027245.V285902.R01.S.doc Version 5.1 Page 24 2. 3. YA32 YA14 El Shaddai the option of a minimum seven day holiday away from the home which they have helped to choose and plan as part of the basic contract price. El Shaddai DS0000027245.V285902.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG 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 El Shaddai DS0000027245.V285902.R01.S.doc Version 5.1 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!