Inspection on 29/09/05 for El Shaddai

This inspection was carried out on 29th 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 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 25/01/07

El Shaddai 27/02/06

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 Octavia Close, 17 Mitcham Surrey CR4 4BY Lead Inspector Liz O`Reilly Unannounced Inspection 29th September 2005 16.30 Octavia Close, 17 DS0000027245.V261259.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 Octavia Close, 17 DS0000027245.V261259.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. Octavia Close, 17 DS0000027245.V261259.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Octavia Close, 17 Address Mitcham Surrey CR4 4BY 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) 0208 646 0159 Ms Brenda Willis Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Octavia Close, 17 DS0000027245.V261259.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Three Adults (M/F) with Learning Disabilities Date of last inspection 28th February 2004 Brief Description of the Service: 17 Octavia Close 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 is situated on the first floor with a bathroom and the remaining two residents’ bedrooms on the second floor. Octavia Close, 17 DS0000027245.V261259.R01.S.doc Version 5.0 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 on 29th September 2005 over 3.5 hours. The inspector had the opportunity to speak with both residents and staff at the home. A sample of records were also examined. 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. Octavia Close, 17 DS0000027245.V261259.R01.S.doc Version 5.0 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 Octavia Close, 17 DS0000027245.V261259.R01.S.doc Version 5.0 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 4 Prospective residents are provided with good information on the home and the service they can expect. The assessment process ensures the individual needs and aspirations of residents are well known prior to admission. Residents are encouraged to visit the home before making a decision to move in. EVIDENCE: The home has produced documents which provide prospective residents with information on the service they can expect should they chose to move in. The registered persons must ensure that copies of the Statement of Purpose and Service User Guide are provided to the Commission. All residents are assessed by staff from social services prior to admission to the home. The home is provided with a copy of this assessment and carry out their own assessment before anyone is admitted. This ensures that staff have a clear understanding of individual needs prior to any resident moving into the home. New residents are introduced to the home in a gradual manner according to individual needs. Residents visit for varying lengths of time, staying for a day, overnight and weekends before moving into the home. Octavia Close, 17 DS0000027245.V261259.R01.S.doc Version 5.0 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 8 & 9 Individual care plans are produced for each resident and reviewed on a regular basis. Residents confirmed they are consulted on day to day activities in the home and about their lives. Risk assessments are in place. EVIDENCE: Staff work with each resident to produce an individual care plan. Care plans were seen to cover the strengths and needs of each person in relation to activities, health, personal hygiene and social skills. Good information was seen to be available on the type of activities each person enjoys. The care plans are signed by staff and residents and are reviewed at least six monthly or more frequently if required. Residents confirmed and records showed that regular house meetings are carried out to discuss any issues. Residents said they had discussed and helped select the menu for the home and what outings they wished to go on. Staff have made progress in making some of the homes procedures more accessible. The complaints procedure has been provided to each resident in a Octavia Close, 17 DS0000027245.V261259.R01.S.doc Version 5.0 Page 9 more accessible format and staff stated they would be working on other key policies and procedures. Staff produce individual risk assessments for residents. A risk assessment was seen to have been set up for one resident who manages their own medication. The resident and staff had signed the document. Risk assessments are reviewed on a regular basis. Risk assessments ensure that residents are supported in an appropriate manner to develop independent living skills and try new activities. Octavia Close, 17 DS0000027245.V261259.R01.S.doc Version 5.0 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): 13, 14, 15 & 17 Residents attend a local day centre. Staff support residents to take part in outings and activities. Residents are encouraged to maintain and develop personal relationships. Residents are provided with a healthy diet and a good variety of food. EVIDENCE: Both residents stated that they enjoyed attending a local day centre four days each week. They also said that when not at the day centre they enjoyed going out to a variety of places. They particularly enjoyed going on regular trips to:Oxford Street and Regents Street, Mc Donald’s, Ikea, art galleries and Battersea Park. Residents said they enjoyed attending church each Sunday and then joining others for a meal together. Octavia Close, 17 DS0000027245.V261259.R01.S.doc Version 5.0 Page 11 Residents confirmed that they were free to invite friends and relatives to visit them in the home. One resident said their sister came to visit at the home on a regular basis. One resident stated that she often visited her boyfriend. Residents gave very positive comments on the food in the home. They said they helped to make up the menu and that staff were “good cooks”. Both residents said they were given enough to eat and could get a snack at any time if they were hungry. Residents said they had enjoyed a holiday in Weymouth earlier in the year and were planning to go to Florida in December of this year. As both residents have lived at Octavia Close for some time the contracts in place do not include as part of the basic fee the option of a seven day holiday away from the home, as required by the National Minimum Standards. Octavia Close, 17 DS0000027245.V261259.R01.S.doc Version 5.0 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): 19 & 20 The physical and emotional health need of residents are met. Medication is well managed and residents can retain and administer their own medication where appropriate. EVIDENCE: Each resident is registered with a local GP. Arrangements are made for residents to receive regular health care checks including attendance at Well Women Clinics. Residents confirmed that they make their own decisions on daily life such as getting up and going to bed. The health and welfare of residents was seen to be protected by the appropriate management of medication within the home. At the time of this inspection one resident was administering their own medication. Risk assessments are in place and staff make regular checks to ensure that the resident is well supported with this task. Octavia Close, 17 DS0000027245.V261259.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Residents reported that they felt their views were listened to. Policies and procedures are in place and training has been supplied to all staff to ensure that residents are protected from abuse. EVIDENCE: Residents stated that if they had any concerns or complaints they would speak to the home owner. One resident said that they would either speak to staff or talk to their relatives. Both residents said that they had never had any problems with the home or had wanted to make a complaint. The complaints procedure has been produced in a more accessible format for the residents in the home. The home keeps a copy of the local authority policies and procedures to be followed should there be an allegation or suspicion of abuse. All staff have received training on the protection of vulnerable adults. At the time of this visit the home was not holding any money for either resident. Octavia Close, 17 DS0000027245.V261259.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25 & 30 Residents are provided with a comfortable, well maintained homely environment. The home was found to be clean and tidy. EVIDENCE: Each resident is provided with their own single bedroom accommodation. The kitchen and dining area is on the ground floor with the lounge on the first floor. Residents bedrooms are on the first and second floor of the home. The furnishings and fittings are of a good standard. Rooms are comfortably furnished and well maintained. Residents bedrooms reflect individual interests and preferences. Both residents said they were very happy with their rooms. All areas of the home were found to be clean and tidy. Residents and staff clearly take a pride in keeping the home tidy. At the time of this inspection work was being carried out to replace the extractor fan in one of the bathrooms. Octavia Close, 17 DS0000027245.V261259.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 34 & 35 Residents were seen to be supported by sufficient staff to meet their needs at the time of this inspection. Staff are offered good opportunities for training EVIDENCE: The home has a very small staff group, with low levels of sickness which offers continuity of care to residents. Agency staff are not employed in this home. All staff are over the age of twenty one. To ensure good communication regular staff meetings are held. Residents are protected by clear recruitment procedures which ensure that necessary checks are carried out on staff before they commence working in the home. These checks include two satisfactory references and Criminal Record Bureau checks. Staff are offered good opportunities for training which ensures residents are cared for by a well informed staff group. Arrangements have been made for one member of staff to attend first aid training in the near future. One member of staff has recently attended fire awareness training. Staff have also attended courses on the protection of vulnerable adults, managing challenging behaviour and understanding autism. Octavia Close, 17 DS0000027245.V261259.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39 & 42 The home is still in the process of completing a quality monitoring system. Checks are carried out on the premises to ensure that the health and safety of residents, staff and visitors are protected. EVIDENCE: The home owner has devised a questionnaire to be used as part of the monitoring of the quality of care in the home. Plans are in place to carry out an annual review of the service. However this had not been completed at the time of this visit. A copy of the report produced following the annual review must be supplied to the Commission. Staff make daily checks on the temperature of hot water accessible to residents. Information to protect the safety of residents in relation to any cleaning materials used in the home is in place. Smoke detectors are checked on a weekly basis to ensure they are in good working order. Octavia Close, 17 DS0000027245.V261259.R01.S.doc Version 5.0 Page 17 Residents were found to be well informed on what they should do if the smoke detectors are activated. One resident described what they should do if the fire were to start on the ground floor. Work has been carried out to have the smoke detectors connected to the electrical system in the home to provide a more secure system. Octavia Close, 17 DS0000027245.V261259.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 x 3 x Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 x 2 x x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 x x x x 3 LIFESTYLES Standard No Score 11 x 12 x 13 3 14 2 15 3 16 x 17 Standard No 31 32 33 34 35 36 Score x x 3 3 3 x CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Octavia Close, 17 Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score x x 2 x x 3 x DS0000027245.V261259.R01.S.doc Version 5.0 Page 19 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 YA39 Regulation 24(1)(2) Requirement The Registered Person must 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 for action 10/01/06 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 2 Refer to Standard YA8 YA14 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. The Registered Person should ensure that residents have 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. Octavia Close, 17 DS0000027245.V261259.R01.S.doc Version 5.0 Page 20 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 Octavia Close, 17 DS0000027245.V261259.R01.S.doc Version 5.0 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. 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