Inspection on 28/09/05 for Erindale (1a)

This inspection was carried out on 28th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Erindale (1a) 11/05/06

Erindale (1a) 05/04/05

Erindale (1a) 23/11/04

Erindale (1a) 08/06/04

Erindale (1a) 21/01/04

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 Erindale (1a) 1a Erindale Plumstead London SE18 2QQ Lead Inspector Ms Pauline Lambe Announced Inspection 28th September 2005 10:00 Erindale (1a) DS0000006759.V249814.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 Erindale (1a) DS0000006759.V249814.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. Erindale (1a) DS0000006759.V249814.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Erindale (1a) Address 1a Erindale Plumstead London SE18 2QQ 020 8317 8200 020 8317 8200 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) Milbury Care Services Limited Mr Asfik Faris Mamode Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Erindale (1a) DS0000006759.V249814.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th April 2005 Brief Description of the Service: 1a Erindale is one of a group of six homes for adults with learning disabilities. The homes are located in the London Borough of Greenwich and Milbury Community Services Limited is the registered care provider. This home is located in a residential area of Plumstead within walking distance of local shops and bus routes. The detached bungalow was built in 1993 and is registered with the Commission for Social Care Inspection to provide accommodation and nursing care for residents with learning disabilities. The property consists of an open plan lounge, a dining room, a kitchen, a laundry, four single and one shared bedroom and a staff office. Adequate toilet and bathing facilities are provided to meet the needs of the residents. Erindale (1a) DS0000006759.V249814.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over 5.25 hours and was carried out as part of the statutory inspection programme. The manager was in charge of the service at the time. The inspection included a tour of the premises, inspection of records, care plans and safety systems. Time was spent talking to residents, relatives, staff and management. The inspector had the opportunity to observe staff interaction with five residents who were in the home during the day. The Commission received feedback comments received from residents, relatives and visiting professionals. What the service does well: What has improved since the last inspection? What they could do better: The home had not been redecorated for a number of years. Bedrooms were particularly in need of redecoration as walls, doors and doorframes were damaged through the use of wheelchairs and mobile hoists. In one bedroom the carpet was quite badly stained and must be cleaned or replaced. The décor of the lounge was tired looking and again the carpet must be kept clean or replaced. The garden was very unkempt which gave the home a neglected appearance and encouraged people to drop litter into it. Other issues that required attention were the maintaining of records in relation to employees including information on staff training. Erindale (1a) DS0000006759.V249814.R01.S.doc Version 5.0 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. Erindale (1a) DS0000006759.V249814.R01.S.doc Version 5.0 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 Erindale (1a) DS0000006759.V249814.R01.S.doc Version 5.0 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): None It was not possible to assess how the home met these standards as no new residents were admitted since the introduction of the national minimum standards. EVIDENCE: From evidence provided at previous inspections the home had a Statement of Purpose and Service user Guide. This provided adequate information to enable prospective residents to make an informed decision about the service. The inspector was told no changes had been made to these documents. The manager was aware of the need to comply with the above standards when considering admission of new residents. Erindale (1a) DS0000006759.V249814.R01.S.doc Version 5.0 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 and 9. From evidence provided staff met the needs of the residents. Residents could not actively participate with care planning and decisions about their lives. Staff endeavoured to involve relatives to this on the resident’s behalf. EVIDENCE: Care plans for two residents were inspected. These included risk assessments, which were supported with relevant care plans. One care plan had been reviewed monthly but the other one had not been reviewed for several months. However the care plan did reflect the current needs of the resident. Life plans were up to date and had been prepared with the involvement of all interested parties. As residents did not have the ability to make informed decisions about their care this was done by the staff and where possible with the involvement of relatives and representatives. Six resident feedback comment cards were sent to the Commission. These had been completed with residents with the support of their key worker. No concerns were highlighted in these. Feedback comment cards received from relatives indicated they were satisfied with the care provided. Comments made included ‘the care is first class’ and ‘residents receive fantastic care’. Erindale (1a) DS0000006759.V249814.R01.S.doc Version 5.0 Page 10 Feedback from professionals who visit the home included positive comments about the quality of care provided. Recommendation 1. Erindale (1a) DS0000006759.V249814.R01.S.doc Version 5.0 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 the following standard(s): 12,13,14,16 and 17. Staff supported residents to access day centres, local services, local leisure activities and to keep in contact with family. Meals were balanced and varied. Relatives contacted said they felt their residents were treated with dignity and respect. EVIDENCE: Residents could not provide feedback on how satisfied they were with their lifestyle. Through reviewing records, observing resident and staff interaction, talking to staff and relatives and considering relative written comments implied staff made efforts to ensure residents led lifestyles suited to their ability. All except one resident attended day centres, were supported to maintain contact with family and enjoyed social activities such as day trips, shopping trips, religious services, theatre visits and holidays. The residents enjoyed holiday breaks away from the home. Currently residents have one holiday a year and the manager was keen to arrange further short breaks for them, which would be taken at the resident’s expense. Before this decision was made the manager must ensure all holiday plans and costs are discussed and agreed with the residents relatives. Erindale (1a) DS0000006759.V249814.R01.S.doc Version 5.0 Page 12 It was not assessed to be in the resident’s best interest that they attended further education, planned to seek employment or independent living. Some residents visited their family at home. Staff escorted one resident to visit their family regularly and the key worker was able to communicate with the resident’s family in their own language. Staff showed respect for resident dignity in the way they conversed with them, closed doors when giving care, ensured they were well dressed and presented. Menus kept and food stock seen showed a varied and nutritious diet was provided. Resident’s required all foods to be served pureed. Food was pureed separately to give it an appetising appearance. Staff said that residents enjoyed having meals out and take away meals. Staff had identified a number of restaurants they could use where the residents dietary needs were taken into consideration. Recommendation 2. Erindale (1a) DS0000006759.V249814.R01.S.doc Version 5.0 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 the following standard(s): 20. Improvements had been made to the management of medicines. These did not pose a risk to the residents. EVIDENCE: Two requirements made at the last inspection in relation to medicines had been met. None of the residents could manage their own medication. Systems were in place to receipt, store, dispose and administer medicines safely. The home had a list of homely remedies agreed with the GP. Records of these medicines were properly kept. Administration records for two residents were reviewed and found to be correct. The home’s policy and procedures say that records for receipt of drugs brought into the home and records for controlled drugs were to be kept for 2 years. This does not comply with regulation, which says records must be kept for 3 years. Recommendation 3. Erindale (1a) DS0000006759.V249814.R01.S.doc Version 5.0 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): 22 and 23. The home had adequate systems in place to manage complaints and allegations or suspicions of adult abuse. Details and outcomes of complaints were well recorded. EVIDENCE: The home had policies and procedures on how to manage complaints and allegations of abuse. Relative feedback indicated they felt confident in the ability of staff to ensure residents lived in a safe environment. They also indicated they were aware of the home’s complaint procedures. Since the last inspection no complaints or allegations of abuse had been made about the service to the home or to the Commission. The inspector was told that staff had received training relevant to the protection of vulnerable adults. None of the residents managed their own finances. Resident income was paid into a Milbury bank account and once the resident contribution was deducted the resident’s personal allowance and DLA was transferred to the resident’s personal account. The home had safe systems in place to manage resident’s money. The cashier was in the home and had checked financial records and found no inaccuracies. Erindale (1a) DS0000006759.V249814.R01.S.doc Version 5.0 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): 24,25,26,27 and 30. The home was not purpose built to accommodate the category of residents living currently living there. The home was clean but in need of redecorating. The garden was very neglected. EVIDENCE: The home was clean and tidy with systems in place to prevent the spread of infection. The home had four single and one shared room. Two single bedrooms were assessed against these standards. Both rooms were clean, tidy, personalised and equipped to meet the needs of the occupant. All bedrooms had ceiling hoists and bedroom doors had automatic closures fitted as a fire safety precaution. As mentioned at the last inspection the home needed some redecoration. This applied especially the bedrooms. The home did not have a planned maintenance programme although the registered person said in their response to the last report that this would be sent to the Commission by June 2005. To date the commission have not received a maintenance programme. A system was in place to record and request repairs and decoration when identified but as the home did not have allocated maintenance technician time this was not always done routinely or quickly. Erindale (1a) DS0000006759.V249814.R01.S.doc Version 5.0 Page 16 The décor of the home does not pose a risk to residents but would make personal and communal space more pleasant. The inspector made contact with Milbury operations manager after the inspection to discuss maintenance issues. The inspector was told that Milbury had been given a sum of money from the PCT, who own the property, towards the cost of redecoration and recarpeting the home. The inspector agreed with the operations manager that the programme for this work would be sent to the Commission and would include start and completion dates. The inspector was also told that a new maintenance technician, newly employed by the company, would be given allocated time to work at this home. The only negative comment made in the relative feedback was in relation to the poor state of décor and the unkempt gardens. From observation the gardens did not provide a pleasant area for residents, they gave the home a neglected appearance from outside and had encouraged passers by to drop litter into it. None of the bedrooms had en-suite facilities and one had a washbasin. Since the last inspection the bathroom decoration was completed and one resident was provided with an armchair suited to their needs. Bathing and moving & handling equipment was regularly serviced. Hot water temperatures were routinely checked and records showed these were maintained within safe limits. Requirement 1. Erindale (1a) DS0000006759.V249814.R01.S.doc Version 5.0 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): 32,34 and 35. Employee files were fairly well completed but there was no evidence on the files of the trained nurses to show that current registration with the Nursing & Midwifery Council had been checked. Staff training files seen were not kept up to date. EVIDENCE: The staff team comprised of a manager, trained nurses and support workers. From the rotas seen the home maintained adequate staffing levels to ensure resident’s needs were met. A number of the support workers had completed level 3 NVQ. The inspector was told that some training, such as fire safety, was done through self-learning and assessment. No up to date records of staff training were available to view. Two employee files were viewed. These contained most of the information required by regulation. There was no evidence on the files of the trained nurses to show that current registration with the Nursing & Midwifery Council had been checked. Requirements 2 and 3. Erindale (1a) DS0000006759.V249814.R01.S.doc Version 5.0 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 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 and 42. Staff demonstrated an awareness of their responsibilities and roles in the home. Systems were in place to ensure attention was given to the safety of residents and others. EVIDENCE: The manager is registered with the Commission and was assessed as having the skills and experience needed to manager the service. The home did not have a recognised quality assurance system in place. A sample of safety systems in place was assessed and found to be up to date and monitored. Moving & handling and bathing equipment was properly maintained, fire precautions were followed and a system was in place to report and access repairs and health and safety issues identified. Fire drills were held at times to include day and night staff. Residents were unable to voice their views of the service. Relative feedback implied satisfaction with the service and the quality of the staff. The Erindale (1a) DS0000006759.V249814.R01.S.doc Version 5.0 Page 19 operations manager held a meeting with relatives to get their views on the service. The outcome of this had not been collated and it was agreed that the Commission would receive a copy of the survey outcome. The Commission receives reports from the home under regulation 26. In response to the last inspection the registered person said they would send the outcome of a collated satisfaction to the Commission by June 2005. To date this has not been received by the Commission. Requirement 4. Erindale (1a) DS0000006759.V249814.R01.S.doc Version 5.0 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 X X X X X Standard No 22 23 Score 4 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 4 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 2 3 2 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 4 14 3 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score x 3 x 2 2 x CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Erindale (1a) Score X X 3 x Standard No 37 38 39 40 41 42 43 Score 3 x 2 x x 3 x DS0000006759.V249814.R01.S.doc Version 5.0 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 A24YA26Y YA28 Regulation 23 Requirement Timescale for action 04/11/05 2 YA34 19 The Registered Person must ensure all parts of the home are kept reasonably decorated and external grounds are safe for use by residents and appropriately maintained. All bedrooms and communal areas must have repairs and redecoration where needed. Carpets must be kept clean or replaced where this cannot be achieved. The gardens must be maintained adequately with the grass being cut regularly, plants and shrubs pruned and the area kept clear of rubbish. A copy of the planned redecoration programme must be sent to the Commission by the date set and must include start and finish dates. The Registered Person must 04/11/05 ensure all information required in relation to employees must be obtained and made available for inspection. A system must be in place to confirm that nurses employed in the home are registered with the DS0000006759.V249814.R01.S.doc Version 5.0 Erindale (1a) Page 22 Nursing & Midwifery Council. 3 YA35 18 The Registered Person must 04/11/05 ensure staff receive training appropriate to the work they perform. Records must be kept of staff training provided and made available for inspection. The Registered Person must 25/11/05 ensure the home has a system in place to review and improve the quality of care provided and to involve residents with this. Copies of any such reviews must be sent to the Commission and made available to residents and their representatives. 4 YA39 24 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 3 Refer to Standard YA6 YA14 YA20 Good Practice Recommendations The Registered Person should ensure care plans are reviewed in line with the requirements of this standard. The Registered Person should ensure all plans for resident holidays, including costs are discussed and agreed with relatives in advance. The Registered Person should ensure guidance in policies and procedures comply with regulation. The medicine policy referred to keeping some medication records for 2 years but the requirement is that all records are kept for 3 years. Erindale (1a) DS0000006759.V249814.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 Erindale (1a) DS0000006759.V249814.R01.S.doc Version 5.0 Page 24 - 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!