CARE HOME ADULTS 18-65
Endsleigh House 46 Endsleigh Gardens Ilford Essex IG1 3EH Lead Inspector
Stanley Phipps Unannounced Inspection 8th August 2005 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 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 Stationary 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. Endsleigh House G55_S41823_Endsleigh House_V243419_080805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Endsleigh House Address 46 Endsleigh Gardens, Ilford, Essex, IG1 3EH Telephone number Fax number Email 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 554 1167 Mr Yuhya Roojee Mr Yuhya Roojee CRH - Care Home 5 Category(ies) of MD - Mental disorder, excluding learning registration, with number disability or dementia - 5 of places Endsleigh House G55_S41823_Endsleigh House_V243419_080805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 25/1/05 Brief Description of the Service: Endsleigh House is a care home providing personal care and accommodation for five people ages 18 – 65 with a history of mental illness, who need support in order to live in the community. It is privately owned and managed by Mr Yuhya Roojee.The home is located on a residential street in Ilford, and is close to all community facilities. These include a wide range of shops, pubs, the post office, entertainment centres, parks and library facilities. All the home’s bedrooms are single, two of which are located on the ground floor and the other three on the first floor. Access to the first floor is via two sets of stairs. There are two reception rooms on the ground floor, one of which is used for dining and the other for relaxation and viewing television. A small conservatory has been constructed for service users who smoke.A rear garden that is domestic in scale is available for the enjoyment of all service users and is easily accessible from the kitchen and smoking area. A group of staff is on hand to provide twenty-four hour care and support to service users. Endsleigh House G55_S41823_Endsleigh House_V243419_080805 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection took place in just over three and a half hours and was timed to coincide with meeting service users who may have been out in the day, assessing the evening activities, including the evening meal and to monitor the service. The service had just completed its first year of operation and was now at full capacity. The inspection found that there have been improvements to the service since the last inspection, but there is still some way to go in meeting the national minimum standards for younger adults. The registered person has demonstrated a willingness to work with the Commission in developing standards in the home. To this end he has complied fully with nine of the requirements made in the last inspection report, with work already starting on the remaining two requirements. An assessment of the finance records, menus, a random sample of service users’ plans, the staffing rota and activities for service users was undertaken. Three service users were spoken to and detailed discussions were held both with the manager and one other of the support staff on duty. This was followed by a tour of the building to include visits to one of the service user’s bedroom. What the service does well: What has improved since the last inspection?
The manager has been able to recruit near enough his full compliment of staff and provided them with some training to enable them to support service users whose needs individually and collectively are complex. The cultural mix of the staff reflected the service user mix, which were twenty percent mixed race,
Endsleigh House G55_S41823_Endsleigh House_V243419_080805 Stage 4.doc Version 1.40 Page 6 twenty per cent mainstream and sixty per cent from a minority ethnic grouping. This mix enabled staff to relate and appreciate the cultural needs of the service user group. Two of the first service users admitted to the home at the time of the first inspection were well settled in the home at the time of this visit. In fact one of them openly commented that he did not wish to move on, as he felt safe and well supported at Endsleigh House. There was evidence that service users were supported to enhance their living skills at the home and this was on an individual basis, as service users were at different levels of functioning and/or capabilities. The manager and staff were good at valuing improvements in every service user, regardless of the size. It can be concluded that the manager is responsive to requirements made by the Commission and this not only benefit all service users, but enhances the overall quality of the service provision. 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. Endsleigh House G55_S41823_Endsleigh House_V243419_080805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Endsleigh House G55_S41823_Endsleigh House_V243419_080805 Stage 4.doc Version 1.40 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 standard(s) (1,4,5) Service users have at their disposal information that enables them to make an informed decision as to whether Endsleigh House is appropriate for them. This is enhanced by the pre-arranged visits to the home, prior to admission, in order to get a feel of how things are done. They also have the peace of mind in not only knowing what is offered in the home’s statement of purpose, but also in a statement of terms and conditions, that is given to each individual. EVIDENCE: The manager has reviewed and updated the home’s statement of purpose in line with the requirements of the Care Homes Regulations 2001. At the time of the visit he was in the process of issuing the updated version to all service users in the home. In conversation with one of the most recent service users, he indicated that, from the moment he saw the home for the first time, – he ‘liked it and felt it would meet his needs.’ At the time he was visiting to assess the suitability of the home and this was a normal part of the admission process. On examination of the service user files, there was evidence of contracts in place for the service users concerned and they contained obligations of both the provider and the service user. The contracts had been reviewed since the last inspection and were now satisfactory. Both parties signed by the document Endsleigh House G55_S41823_Endsleigh House_V243419_080805 Stage 4.doc Version 1.40 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 standard(s) (7) Support and assistance is made available to all service users in negotiating their daily routines and objectives. This is to ensure that they are focussed, practical and realistic about their individual aspirations. Service users should have greater access advocacy services if even as an option for the future. EVIDENCE: The needs of service users are complex and varied and levels of support to achieve individual objectives differ. Whatever the difference staff are able to provide the support to enable this. One good example is where a service user identified that he had difficulty in managing his finances and discussed this with the manager. Support was agreed between the manager and the service user for them to visit the post office and withdraw fifty pounds at a time. An arrangement was then made to release five pounds per day and this from the service user’s point of view has been working pretty well. There was also evidence of service users making collective decisions and the forum most widely used for this, was service user meetings. One example of this was a recent holiday to Margate 15/705 to 20/7/05, which all the service users organised with the staff and subsequently attended. Two service users spoke of having a good experience during the break to Margate and the manager confirmed that it was a positive experience for them all i.e. service users and staff alike. The manager obtained advocacy information from PALS (Patient Advisory Liaison Service) – an NHS project. This could be widened to a more
Endsleigh House G55_S41823_Endsleigh House_V243419_080805 Stage 4.doc Version 1.40 Page 10 general system that enables service users to gain advocacy support on any aspect of their lives. This was discussed in detail with the manager of the home, as the PALS service on it’s own, is inadequate to cover all aspects of advocacy, for example, welfare, housing, finance, quality of care in the home. Endsleigh House G55_S41823_Endsleigh House_V243419_080805 Stage 4.doc Version 1.40 Page 11 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 standard(s) (15,17) All service users have opportunities to develop and maintain social and personal networks of their choosing. This gives them something invaluable to look forward to. Meals although satisfactory in content, could be more varied and reflective of service users’ cultural needs. EVIDENCE: There is evidence that all service users have contact with their relatives and this is at various levels and frequencies. The contacts ranged from phone calls and occasional visits by relatives to one service user actually spending time with his relatives every fortnight. One service user spoke at length about the relationship between his sister and himself. He spoke of going to the cinema with her in the past and plans they had for the future. He is really positive about maintaining this relationship and feels that he has something more than his job, managing the symptoms of his illness and living at Endsleigh House. The manager and staff appreciate the value of such relationships and they work effectively to help maintain them, once they have been established. There was no clear evidence that service users have developed close and intimate relations, although one service user openly expresses a desire to acquire a partner. In this respect, the manager was observed providing
Endsleigh House G55_S41823_Endsleigh House_V243419_080805 Stage 4.doc Version 1.40 Page 12 support and guidance to the service user concerned to ensure that his wishes are safely explored. The approach undertaken was satisfactory and guidance was offered to minimise all risks to the service user and in effect any relapse of his illness. With regard to meals in the home, a varied four-week menu was available for inspection. However it was not reflective of the cultural mix of the service user group and in some respects reflected more that of an English cuisine. The manager stated that they had roast and do have curry and whilst that was not a matter for dispute, it was clear that they were not recorded on the menu, neither were they recorded anywhere else. This was unsatisfactory and needs to improve. It was discussed during the inspection with the manager that there was room for more service user involvement in determining the menus at Endsleigh House. Another area marked for improvement was for staff to be more aware of the need for storing food safely. In this case particularly, the dry food storage. There were a number of instances in which food was not sealed off in a manner that was safe and this was pointed out directly to the manager. It is important that this awareness be passed on to service users for their development in food safety. The score for this standard is reflective of the number of areas identified for improvement in this section of the report. Endsleigh House G55_S41823_Endsleigh House_V243419_080805 Stage 4.doc Version 1.40 Page 13 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 standard(s) (20) Service users at Endsleigh House are reassured that they well supported in dealing with their medication, which they are aware is an integral part of managing the problems associated with their illnesses. EVIDENCE: None of the services users are currently able to administer their own medication. An assessment of how medication is handled in the home was undertaken and this was found to be satisfactory. They are kept locked in a cupboard with the keys retained by the shift leader. Each individual’s medication is kept in a dosset box and the pharmacist takes the responsibility for filling it. Medication charts were accurate and well maintained. Staff spoken to, were aware of the protocols for handling medication. Most of the service users are prompted to have their medication, although some individuals actually come and request, when the medication is due. Endsleigh House G55_S41823_Endsleigh House_V243419_080805 Stage 4.doc Version 1.40 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 standard(s) (23) Adult Protection procedures and protocols are in place to ensure that service users are protected from harm. However staffing training in adult protection is key to ensuring appropriate implementation of the procedures. EVIDENCE: A satisfactory adult protection procedure is now in place at the home, as the manager reviewed this document to bring it in line with the requirements of national minimum standard 23.5 for younger adults. The manager also has a copy of the Redbridge Adult Protection Protocol and both documents referred to above, are easily accessible to staff. There have been no adult protection issues in the home, however training in adult abuse needs to be undertaken by all staff. Service users records including their financial records were accurate and secure. Endsleigh House G55_S41823_Endsleigh House_V243419_080805 Stage 4.doc Version 1.40 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 standard(s) (24,25,27,30) Service users enjoy a clean and comfortable environment when residing at Endsleigh House and this includes their private spaces. More attention needs to be given to the safety of both internal and external aspects of the environment. However, for the enhancement of private spaces, service users must be allowed to personalise their bedrooms. EVIDENCE: The home was generally clean and maintained to a good standard. All service users are happy with the physical condition of the home, however a number of areas were identified for improvement. They included broken tiles in the kitchen in need of replacement, the casing of pipes of hot and cold water pipes in the upstairs quiet room, minor redecoration around the wall leading to the kitchen door, the replacement and stabilising of all loose and cracked tiles on the rear patio (as a matter of urgency) and to secure the rear fence. A key feature of enhancing the homeliness of the environment is to acquire the service users views towards the types and appropriateness of hanging pictures on the wall of the passageway from the front door and up the stairwell. These walls are in the main, bare. There was also a lack of plants (real) that could add atmosphere to the home and this could be explored with service users. Toilets and bathrooms are adequate for the needs of service users, however
Endsleigh House G55_S41823_Endsleigh House_V243419_080805 Stage 4.doc Version 1.40 Page 16 the bathroom on the first floor was extremely plain. It did not contain a mirror, towel rail or pictures of any kind. This must be improved and can be undertaken in consultation with the service users. All service users spoken to, were happy with the size and layout of their bedrooms, however one service user expressed a concern that he was not allowed to hang his pictures on the walls. The reason given was that the pictures were assessed as being too heavy for the walls. This matter was discussed with the manager and the service user. Ideas were subsequently exchanged for the safe and secure suspension of the pictures and the manager proposed to follow this through. Endsleigh House G55_S41823_Endsleigh House_V243419_080805 Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) (31,32,35) Service users at Endsleigh House benefit from having a dedicated manager and staff team who work well together to enhance the quality of services they receive. EVIDENCE: There are job descriptions in place for all staff working in the home and staff were well aware of their responsibilities. This was enhanced by the manager providing them with a copy of the General Social Care Council’s code of conduct for staff. A key worker system is in place at the home and service users spoken to knew their key worker and their role. Service users also expressed their satisfaction with staff working with them. The manager, as part of developing staff, has produced a training and development plan for them. This maps out the training for staff based on the needs of the service user group. The manager also provided evidence of his affiliation to the Redbridge Training Collaborative, which would enable him to access at no cost, vital training for the staff team and himself. Although the manager must ensure that all staff receive abuse training as a matter of priority, other training has been provided. This included food hygiene for up to four staff and basic training in mental health for most of the team. The manager provides the mental health aspect of the training. He however acknowledged, that in meeting the diversity of specialist needs of the service user group, more intense training is required around mental health.
Endsleigh House G55_S41823_Endsleigh House_V243419_080805 Stage 4.doc Version 1.40 Page 18 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) (37,39,42,43) There are some good management systems in place to enable service users to receive a satisfactory standard of care at Endsleigh House. This is enhanced by having an experienced manager who leads a staff team that is willing to work with the service user group. EVIDENCE: The registered manager has a professional qualification in the field of mental health. As part of his commitment to improve his management expertise and the quality of service provision, he has commenced his NVQ level 4 in Management and Care. Service users were observed engaging comfortably with the manager throughout the inspection and they all expressed their satisfaction with the management of the home. The views of service users are obtained informally in service user meetings and the manager has started undertaking his annual service user survey with responses obtained, from forty per cent of the service user group. Improvements have been made with regard to promoting the health and safety of service users. To this end risk assessments have been completed on all safe
Endsleigh House G55_S41823_Endsleigh House_V243419_080805 Stage 4.doc Version 1.40 Page 19 working practice topics, including infection control. Up to three staff are qualified in first aid and have had health and safety training at induction and health and safety generally is of a satisfactory standard. It should be noted that that dried food storage has been addressed earlier in this report as an area for improvement and as such is not repeated in the health and safety assessment, although it put service users at risk. The manager has produced a business plan for the service and has there was evidence that the service is financially viable. He advised that he has a private accountant who audits his accounts. A random sample of service users finances was assessed and this was satisfactory. It was concluded that the home was satisfactorily managed. Endsleigh House G55_S41823_Endsleigh House_V243419_080805 Stage 4.doc Version 1.40 Page 20 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 x x 3 3 Standard No 22 23
ENVIRONMENT Score x 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score x 2 x x x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 3 2 x 2 x x 3 Standard No 11 12 13 14 15 16 17 x x x x 3 x 1 Standard No 31 32 33 34 35 36 Score 3 3 x x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Endsleigh House Score x x 3 x Standard No 37 38 39 40 41 42 43 Score 3 x 3 x x 3 3 G55_S41823_Endsleigh House_V243419_080805 Stage 4.doc Version 1.40 Page 21 no 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 YA 17 Regulation 12,13 Requirement The registered manager is required to ensure that service users are; a) actively consulted with records kept of dietary preferences, b) provided with meals that are in line with their needs and culture and c)keep a record of all meals consumed by service users. The registered manager is required to ensure that all staff handling food receive training in basic food hygiene and store food safely, sharing their knowledghe with service users. The registered manager is required to ensure that all staff receive trianing in adult protection. The registered manager is required to ensure that service users are allowed to personalise their bedrooms to their choice and lifestyles. The registered manager is required to address all the areas marked for improvement in the evidence section of the environment standards (24-30) of this report. Timescale for action From 8th August 2005 & Ongoing. 2. YA 17 !2,13 31st October 2005 3. YA 23 13 31st October 2005 20th September 2005 30th September 2005 4. YA 25 23 5. YA 27 23 Endsleigh House G55_S41823_Endsleigh House_V243419_080805 Stage 4.doc Version 1.40 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. Refer to Standard YA 7 Good Practice Recommendations The registered manager should make information on advocacy services available to all service users. Endsleigh House G55_S41823_Endsleigh House_V243419_080805 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection Ferguson House 113 Cranbrook Road Ilford, Essex IG1 4PU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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