Inspection on 05/04/05 for Erindale (1a)

This inspection was carried out on 5th April 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Erindale (1a) 11/05/06

Erindale (1a) 28/09/05

Erindale (1a) 23/11/04

Erindale (1a) 08/06/04

Erindale (1a) 21/01/04

Similar services:

Ashlong House

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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 Erindale 1a Erindale Plumstead SE18 2QA Lead Inspector Pauline Lambe Unannounced 5th April 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. Erindale Version 1.10 Page 3 SERVICE INFORMATION Name of service Erindale Address 1a Erindale Plumstead SE18 2QA 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) 020 8317 8200 020 8317 8200 Milbury Care Services Mr Asfik Mamode Care Home 6 Category(ies) of N Care Home with Nursing 6 registration, with number of places Erindale Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 23/11/04 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. The 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 nursing care for residents with learning disabilities. The home consists of an open plan lounge, a dining room, a kitchen, a laundry, four single and one shared bedroom and a staff office. The home has adequate toilet and bathing facilities to meet service user needs. Erindale Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 4.5 hours and was carried out as part of the statutory inspection programme. The inspection included a tour of the premises, inspection of records, care plans and safety systems. Three staff spoke to the inspector and the inspector was able to observe staff interaction with four residents present during the day. Some relatives were contacted by phone after to inspection to get their views of the service. The inspector thanks all who participated with the inspection. What the service does well: What has improved since the last inspection? What they could do better: The registered person must ensure the system used to administer medication is reviewed to ensure safe practice. The bedroom decoration could be improved. Though this did not pose a risk to residents it would make the environment more pleasant. General repairs could be carried out more speedily for example the rear garden gates had been broken for some months. This left the premises open to intrusion by local residents. Management should improve the system to monitor review the service through a more formal process of inclusion of residents, relatives and others. Erindale Version 1.10 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Erindale Version 1.10 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 Erindale Version 1.10 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) 0 As no residents had been admitted to the home since the introduction of the National Minimum standards these standards were not assessed on this occasion. 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. Erindale Version 1.10 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) 6,7,8,9and 10 Staff in the home adequately met the needs of the residents. As residents could not be involved with their care planning staff endeavoured to involve relatives on their behalf. EVIDENCE: Care plans for two residents were inspected. These included risk assessments, which were supported with relevant care plans. Although it was evident care plans were reviewed, some had not been reviewed for several months. Life plans were up to date and had been prepared with the involvement of all interested parties. Residents in the home did not have the ability to take part in care planning and decisions about their care. This was done by the staff and where possible with the involvement of relatives and representatives. Two resident’s relatives were contacted by phone following the inspection. Both were very satisfied with the quality of care provided and with the way staff met their resident’s needs. Relatives said residents were always well presented, treated with dignity and staff communicated with them appropriately. Erindale Version 1.10 Page 10 The home had a policy and procedure on confidentiality and records seen were respectively written and safely stored. Recommendation 1. Erindale Version 1.10 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) 11,14,15, and 17 Staff supported residents to access day centres, local services and 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 their lifestyle. Looking at records, talking to staff and relatives assessed how the home ensured residents lead satisfactory lifestyles. All residents attended day centres, were supported to maintain contact with family and enjoyed social activities such as day trips, shopping trips and holidays. One resident visited their family regularly and was escorted by the key worker who could communicate with the resident’s family in their own language. Menus kept and food stock showed a varied and nutritious diet was provided. Resident’s required all foods to be served pureed. Food was pureed separately to ensure it looked appetising. Erindale Version 1.10 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 standard(s) 18,19 and 20 Suitable arrangements were in place to ensure the personal and healthcare needs of the residents were met. The system in place for the administration of medicines could place service users at risk. EVIDENCE: Residents were registered with a G.P. Evidence was provided to show when care was provided by other professionals such as dentist, dietician and hospital consultants. Care plans showed how personal care was provided with each resident having a weekly individual ‘pampering day’. None of the residents had pressure sores and attention was given to ensuring systems were in place to prevent this happening. Skin care, pressure relief mattresses and positioning of residents were well managed. None of the residents could manage their own medication. Systems were in place to receipt, store, dispose and administer medicines. Staff ‘potted up’ medicines into medicine cups with resident’s names prior to administration. This was not assessed as safe practice. The manager agreed to address this with immediate effect. The home had homely remedies and records for one of these was inaccurate. Administration records for two residents were reviewed. An inaccuracy was noted on one record where one dose of a medicine had not been signed for at the time of administration. At the time of writing this report Erindale Version 1.10 Page 13 the manager advised the Commission verbally that medications were no longer ‘potted up’ but administered one at a time Requirements 1 and 2. Erindale Version 1.10 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) 22 and 23. The home had adequate systems in place to manage complaints and adult protection. Details and outcomes of complaints were well recorded. EVIDENCE: The home had policies and procedures on how to manage complaints and allegations of abuse. Relatives contacted said they felt confident in the ability of staff to ensure their resident lived in a safe environment. They also said that if they had a concern they would feel comfortable talking to the manager of a member of staff. Since the last inspection no complaints or allegations of abuse had been made about the service to the home or to the Commission. Erindale Version 1.10 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) 24,25,26,27,28,29,and 30. The home was not purpose built to accommodate the category of residents living currently living there. The home has very little storage space. Management and staff make efforts to ensure the needs of the residents are met within the environment. EVIDENCE: The home was clean and tidy. The home had four single and one shared room. Two bedrooms were assessed against these standards, one shared and one single. 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. Screening was provided in the shared room. Bedrooms would benefit from repainting. This does not pose a risk to residents but would make personal space a more pleasant environment. None of the bedrooms had en-suites or washbasins. Since the last inspection a new assisted bath and a sluice machine had been provided. The bathroom had new flooring but the damage to the walls, from the work undertaken, had not been repaired. Erindale Version 1.10 Page 16 Residents had their own individually built wheelchairs. The manager said that he was in the process of buying some lounge furniture specifically suited to the residents positioning needs. Externally the garden needed attention such as pruning of shrubs and cutting the grass. Two rear garden gates had been knocked down for safety reasons some months ago but had not been repaired. This left the home vulnerable from intrusion by local children and others. Requirement 3. Erindale Version 1.10 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) 31,33,35 and 36. Rotas reviewed showed the home had the agreed number and skill mix staff on duty to meet the needs of the residents. The home benefited from having a stable team who had access to relevant training and formal supervision. EVIDENCE: The home benefited from having a stable staff team. The staff team comprised of a manager who had two management days a week, qualified nurses and care assistants. The home did not employ domestic staff. Cooking and cleaning was part of staff job descriptions. Seven care assistants had achieved level 3 NVQ and two had yet to complete Level 2 NVQ. Staff who spoke to the inspector said they were provided with adequate and relevant training and support from senior staff in the home. Staff had job descriptions and clearly defined roles within the team. Recruitment files were not inspected on this occasion as no new staff members were employed since the last inspection. There was evidence to show that systems were in place to provide staff meetings and formal staff supervision sessions. Relatives contacted by the inspector said they were very satisfied with how the staff interacted with them and the residents. They said staff contacted them when appropriate about their relative’s health and well being. Erindale Version 1.10 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, 40 and 42. Senior staff supported the manager to provide clear leadership in the home. Staff demonstrated awareness of their roles and responsibilities. Systems in place ensured attention was given to service user safety. EVIDENCE: At previous inspections the manager 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. Residents were unable to voice their views of the service. Relatives who spoke to the inspector were complimentary about how they were involved with the service. They were satisfied with the level of involvement they had. A sample of safety systems in place was assessed and with the exception of the fire alarm system, which was overdue a service and the public liability insurance certificate, which was out of date these were adequately monitored. Prior to completion of this report verbal confirmation was given to the Erindale Version 1.10 Page 19 Commission that the fire alarm system was serviced on 13/4/05 and a new public insurance certificate was obtained. Since the last inspection the registered person had introduced a new system of training for staff in relation to health & safety, fire safety and food hygiene. This was done through self learning, self assessment and outcomes reviewed by senior management. The home will continue to hold practice fire drills and induct new staff on the safety systems within the home. Requirements 4 and 5. 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 Erindale Score 4 3 3 3 Standard No 24 25 26 27 28 29 30 Score 3 3 2 2 3 3 3 Page 20 Version 1.10 10 LIFESTYLES 3 Score STAFFING Standard No 11 12 13 14 15 16 17 4 x x 3 3 x 3 Standard No 31 32 33 34 35 36 Score 3 x 3 x 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 2 x Standard No 37 38 39 40 41 42 43 Score 3 x 3 x x 2 x Erindale Version 1.10 Page 21 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 20 Regulation 13 Requirement The Registered Person must ensure records are kept for all medicines brought into the home including homely remedy medicines. The Registered Person must ensure medicines are dispensed individually at the time of administration and not prepared in advance. Medicines must be signed for at the time of administration. The Registered Person must ensure the premises are maintained in good repair both internally and externally. The bathroom walls must be repaired and redecorated following the fitting of the new bath. The garden gates to the rear of the home must be repaired. Plans must be made to redecorate individual bedrooms. The Registered Person must ensure a system is in place to review, monitor and improve the qaulity of care provided in the home. (Timescale of 14/1/05 was not met) Version 1.10 Timescale for action 17/5/05 2. 20 13 17/5/05 3. 27 23 31/5/05 4. 39 24 31/5/05 Erindale Page 22 5. 42 13 The Registered Person must ensure the fire alarm system is serviced regularly. 17/5/05 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 6 Good Practice Recommendations The Registered Person should ensure care plans are reviewed in line with the requirements of this standard. Erindale Version 1.10 Page 23 Commission for Social Care Inspection Riverhouse 1 Maidstone Road Sidcup Kent 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 Version 1.10 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!