Inspection on 18/12/06 for Elwis House, 1

This inspection was carried out on 18th December 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Elwis House, 1 21/08/08

Elwis House, 1 08/06/07

Elwis House, 1 18/01/06

Elwis House, 1 22/09/05

Elwis House, 1 01/11/04

Elwis House, 1 23/04/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

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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 Elwis House, 1 2-8 Bell Green Lane Sydenham London SE26 5TB Lead Inspector Pam Cohen Unannounced Inspection 18th December 2006 10:00 Elwis House, 1 DS0000025617.V324274.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 Elwis House, 1 DS0000025617.V324274.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. Elwis House, 1 DS0000025617.V324274.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elwis House, 1 Address 2-8 Bell Green Lane Sydenham London SE26 5TB 0208 778 9485 0208 297 1207 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) Providence Project Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Elwis House, 1 DS0000025617.V324274.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for 4 people with learning disabilities of whom up to 3 may be over 65 years and up to 3 may also have a physical disability 18 January 2006 Date of last inspection Brief Description of the Service: Elwis House provides a residential service to a maximum of four people with learning disabilities and high support needs, including older people suffering from dementia. The home is run by a registered charity PLUS, which has recently been formed by the former provider ‘The Providence Project’, merging with another charity, LINC. Accommodation is provided in a purpose built ground floor home, designed to meet the needs of people using wheelchairs. All residents have their own bedroom. The area is served by public transport and has a selection of shops and a supermarket. At the time of this inspection there were no vacancies. The organisation was not able to provide the commission with information about the range of fees for service users in the home. Elwis House, 1 DS0000025617.V324274.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the afternoon of 18th December. The home was decorated for Christmas and all the service users were there, with a visitor from another home run by the organisation. The inspector was not able to obtain a lot of information from the service users due to their disabilities, but their demeanour and the answers they were able to give seemed to show that they were content. The manager was in the home and facilitated the inspection and two staff on duty spoke with the inspector. An appointment was made to go back to the home two days after the main inspection to see some documentation which had not been available. The inspector also spoke to the service manager on the phone. 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. Elwis House, 1 DS0000025617.V324274.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 Elwis House, 1 DS0000025617.V324274.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 good. This judgement has been made using available evidence including a visit to this service. Evidence available shows that prospective service users could be sure that the home could meet their needs, if admitted there. EVIDENCE: No new service user has been admitted to the home for some years. However, the organisation’s policy and the manager’s knowledge of the process would seem to show that no service user would be admitted without a thorough assessment of their needs. Elwis House, 1 DS0000025617.V324274.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): 6,7,8, 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Documentation of service users’ needs is not brought together a way that means that service users can be sure that all their needs are addressed or reviewed. Service users are supported well to be as independent as possible. EVIDENCE: Service users at Elwis House have complex care needs. They were seen to be content and looked well cared for. A letter was also seen on a service user’s file where a care manager wrote that he was “extremely impressed by the support given to the service user.” Individuals’ files contain a lot of information about what their needs are and how these should be met. However this information is not ordered in any way into an individual plan which can then be monitored and reviewed to ensure that all required support is being given. There are also areas where there is not adequate detail, for example what support is needed in giving personal care. There was also not available clear evidence of a detailed review of changing needs and goals. Elwis House, 1 DS0000025617.V324274.R01.S.doc Version 5.2 Page 9 Discussion with the manager and reading of files showed that staff make every effort to ensure that service users make as many decisions as possible about their life. These decisions can be communicated verbally by one service user, but with other service users staff need to judge from facial expression or from experience of what the service user has seemed to enjoy. Service users are also supported to participate as much as possible in the routines of the house. Two service users do not have advocates and the staff advocate on their behalf. Risk assessments are completed which showed that service users are supported to take part in activities in as safe a way as possible. These risk assessments were not in the home at the time of the main inspection. Elwis House, 1 DS0000025617.V324274.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): 12,13,14,15,16,17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. More thorough assessment of service users wishes and abilities in relation to social activity is needed to be sure that they are receiving as much stimulation as wished and needed. Ongoing links are well maintained, service users’ rights are respected and food provision is good. EVIDENCE: A range of activities is available inside and outside the home and service users are supported to access the community. Religious observance is also supported, as is access to family and friends. After inspection of records and discussion with the manager it was not however clear whether more could be done in these areas or not. Two of the service users are of pensionable age and suffer from dementia. Another is at the moment almost bed bound; all also have learning disabilities of varying degrees. As such it is not easy to find a suitable range of enjoyable and rewarding social activities for them. However as full an assessment as possible of their respective wishes and Elwis House, 1 DS0000025617.V324274.R01.S.doc Version 5.2 Page 11 abilities in this area would be the base line for demonstrating that every available possibility has been looked at and that as full an activity timetable as possible had been accessed. Tracking of activities, to show what service users participate in, is not yet being done consistently. The manager said that the placing authority would not consider funding the price of a holiday and it is therefore recommended that the organisation consider including the cost of a 7 day holiday as part of the contract price. There was good written and verbal evidence that considerable thought has been given to where service users’ rights could be met, and where that was not possible. Food provision was seen to be well provided for, on an individual basis, with service users involved as much as possible. Elwis House, 1 DS0000025617.V324274.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users receive appropriate personal support. Their health care needs, including medication administration, are well met. EVIDENCE: Observation showed that staff interaction with service users was good and respectful. This together with conversations with staff who were knowledgeable about the care needed by service users would seem to demonstrate that the appropriate personal support would be delivered in the required way. There was good evidence on file to show that the home works closely with the local GP practise as well as other health professionals such as physiotherapist, district nurse or psychologist, the community dentist and chiropodist. This work together with monitoring and recording means that service users’ health care needs are met. Medication administration was checked and was judged to be good. Elwis House, 1 DS0000025617.V324274.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. Policies, procedures and training are in place to facilitate complaints and to protect service users from abuse. EVIDENCE: The home has an up-to-date complaints policy and work is in hand across the organisation to make this as accessible as possible to service users. The commission has received no complaints about the home and the home had received no complaints. The home also has a whistle blowing policy which staff are made aware of at induction. There is an adult protection procedure but this is out-of-date and does not cover all necessary areas. The organisation is in the process of updating the policy and intend that this should be done by February 2007. All staff have training in the protection of vulnerable adults. A new member of staff confirmed that he had received this as part of his induction training. Elwis House, 1 DS0000025617.V324274.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): 24,25,27,28,30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a comfortable home which is safe and well suited to their needs. EVIDENCE: All service users have large single room that had been personalised to allow service users to follow their own life style. One bedroom is en-suite and the home also has two toilets, two bathrooms and a shower, all of with suitable locking mechanisms in place to enable privacy. There is a suitable bath hoist in place. Toilets were located close to bedrooms and the dining area. There is a communal kitchen/dining room as well as a comfortable lounge. Lounge. The garden is accessible and has raised flowerbeds and borders, to enable service users in wheelchairs to garden if they wish. All communal space is comfortable, well furnished and homely. There were no areas of concern about safety in the environment and on the day of inspection the home was clean and hygienic throughout. Elwis House, 1 DS0000025617.V324274.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): 32,33,34,35,36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Well-trained and supervised staff are deployed in sufficient numbers to ensure good support for service users. EVIDENCE: There continues to be three staff on duty during the day and a waking staff at night together with sleep-in back up; this is sufficient for the service user group in the home. Conversation with staff on duty showed them to be committed to supporting the service users. Training is good starting with induction and foundation courses to LDAF standards. Mandatory training for areas of Health and Safety, including Moving and Handling are up-to date. There is also a good range of training to deal with the individual needs of service users including such areas as dementia and epilepsy. The home’s recruitment procedures could not be checked as the manager was unable to access the recruitment sheets which should be held in the home. For this reason the existing requirement regarding recruitment will remain in place until documentation is place for the commission to inspect. Elwis House, 1 DS0000025617.V324274.R01.S.doc Version 5.2 Page 16 Staff receive regular supervision which is recorded. At the main inspection these supervision sheets were not available although they were seen at the subsequent visit. Elwis House, 1 DS0000025617.V324274.R01.S.doc Version 5.2 Page 17 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): 37,39,41,42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home does not formally gather the views of interested parties or involve them in an annual development plan. The lack of some documentation that was not available in the home could impact negatively on service users’ care. EVIDENCE: The manager has been in post for some time and has applied for registration with the commission. He has relevant experience with this service user group and is also undertaking the NVQ 4 in management. Staff spoken to during the inspection said that management support in the home was good. The person-in-control does monthly monitoring visits to the home. Across the organisation there is a quality monitoring system with commissioning bodies. There is also a management board with a service user representative. However, the home does still not operate a formal quality assurance exercise Elwis House, 1 DS0000025617.V324274.R01.S.doc Version 5.2 Page 18 with all interested parties. The organisation has a business plan but the home itself does not yet have an annual development plan. There is within the home an issue about office systems and this resulted in some necessary documentation not being available for the inspection. This has been an ongoing issue and needs to be resolved. Health and safety systems checked were generally found to be good, but the staff must ensure that the cupboard containing substances hazardous to health is always kept locked. Elwis House, 1 DS0000025617.V324274.R01.S.doc Version 5.2 Page 19 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 3 26 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 3 36 3 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 2 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X 2 2 X Elwis House, 1 DS0000025617.V324274.R01.S.doc Version 5.2 Page 20 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 YA6 Regulation 15(1) Timescale for action The registered person must 15/01/07 ensure that individual plans are drawn up covering all aspects of personal and social support and health care needs. The registered person must ensure that reviews of care plans give clear evidence of monitoring, evaluation, review and update of objectives. Target dates of 01/05/05 and 30/04/06 not met. The registered person must ensure that a full assessment is made of each service user’s wishes and abilities in relation to activities. The Registered Manager must ensure that the ‘Keeping Track’ forms are completed consistently so that the home (and the Commission) can fully assess if service users are doing enough during their week Target date of 30/04/06 not met. The registered provider must ensure that all statutory checks, to ensure suitability of staff, are DS0000025617.V324274.R01.S.doc Requirement 2. YA6 15 (1) & (2) 31/03/07 3 YA12 14(1)(a) 16(2)(m) 31/03/07 4. YA14 15,16(2) (m) & (n) 28/02/07 5. YA34 19 31/03/07 Elwis House, 1 Version 5.2 Page 21 6. YA39 24(1)(2) & (3) 7. YA39 24(1)(2) & (3) 8. YA41 17(1)(a)(b )(2)(3) 13(4)(a) 9. YA42 conducted and inform the decision to appoint. In particular the registered provider must ensure that: - All previous work and education history is obtained and any gaps explored. - Appropriate references are consistently sought and received before applicants start work. - Existing files are reviewed. - Appropriate steps are taken to ensure that the checks are consistent with the requirements of the national minimum standards and regulations and the home’s own policy. Target date of 31/03/06 not met. The Registered Individuals must ensure that full consultation takes place with service users, their families and other stakeholders asking them how they feel about all aspects of the service they are offered. This consultation must occur at least annually and must be recorded. Target date of 31/03/06 not met. The Registered Individuals must ensure that there is an individual annual development plan in place for the home that is based on the views of service users, relatives and other stakeholders and shows how the home aims to improve in the forthcoming year. Target date of 31/03/06 not met. The registered person must ensure that all documentation required by regulation is available in the home at all times. The registered person must ensure that the COSHH cupboard is locked at all times. 30/06/07 30/06/07 31/01/07 31/01/07 Elwis House, 1 DS0000025617.V324274.R01.S.doc Version 5.2 Page 22 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 1. Refer to Standard YA7 YA14 Good Practice Recommendations It is recommended that service users be given the opportunity to have independent advocates to work on their behalf. It is recommended that the organisation consider making part of the basic contract price, the option of a minimum seven-day annual holiday outside the home for each resident. The Registered Individual should consider using a professionally recognised quality assurance tool to fully assess the service and develop improvement plans. 3. YA39 Elwis House, 1 DS0000025617.V324274.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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. 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