Inspection on 01/11/06 for Fenwick Road, 29

This inspection was carried out on 1st November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Fenwick Road, 29 30/10/08

Fenwick Road, 29 07/01/06

Fenwick Road, 29 24/06/05

Fenwick Road, 29 24/02/05

Fenwick Road, 29 14/06/04

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 Fenwick Road, 29 London SE15 4HS Lead Inspector Pam Cohen Unannounced Inspection 1st November 2006 14:30 Fenwick Road, 29 DS0000007096.V317981.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 Fenwick Road, 29 DS0000007096.V317981.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. Fenwick Road, 29 DS0000007096.V317981.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fenwick Road, 29 Address London SE15 4HS 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) 020 7732 5261 020 7732 5261 fenwick@saffronland.co.uk Saffronland Homes Mariam Moshood Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Fenwick Road, 29 DS0000007096.V317981.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7 January 2006 Brief Description of the Service: The home provides care for three adults with learning difficulties. It is managed by the Saffronland group, which is a private provider. The house is an end of terrace property between Peckham and East Dulwich and is well located for transport links, local shops and community facilities. Each service user has their own room, one of which is en-suite. There is a front and back garden and on-road parking. On the day of the visit there were no vacancies and weekly fees were £1340. Fenwick Road, 29 DS0000007096.V317981.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 1st November. All three service users were in the home and although they were not able to communicate with her directly. The inspector was able to see the interactions between two of them and the staff. The premises and documentation were checked and staff assisted with the inspection. The inspector returned the next week to meet with the manager, at which time she was also able to talk to the father of one of the service users. 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 Fenwick Road, 29 DS0000007096.V317981.R01.S.doc Version 5.2 Page 6 be made available in other formats on request. Fenwick Road, 29 DS0000007096.V317981.R01.S.doc Version 5.2 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 Fenwick Road, 29 DS0000007096.V317981.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have information on the home, and a statement of terms and conditions, but these are not yet in a format accessible for this service user group. EVIDENCE: The home has a service user guide which should be put into a format which is accessible for service users; the manager is liaising with other professionals to develop the best format for these documents. No new service users have come into the home since the last inspection and so pre-admission procedures could not be checked. Service users have an up-to-date statement of terms and conditions on their file. Fenwick Road, 29 DS0000007096.V317981.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good care plans and risk management strategies mean that staff can enable service users to live as independently as they wish and are able. EVIDENCE: The home has detailed and up-to-date, person-centred care plans for each service user which cover all areas of their lives where support is needed. Achievements are noted and goals made for the future, including recommendations brought forward from review meetings. The home continues to enable service users to make as many decisions about every day life as possible and this is reflected in daily diaries. The father of a service user confirmed that his daughter only takes part in activities when she wants to. All service users have an advocate. Service users’ care plans showed good use of risk assessments and risk management strategies to enable service users to take part in as many activities as possible. Fenwick Road, 29 DS0000007096.V317981.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 good. This judgement has been made using available evidence including a visit to this service. Service users have access to a good range of community-based activities and are supported to maintain contact with family and friends. Their recreational options could be increased by more evening activities. Additional care also needs to be taken to ensure that their individual dietary needs are met. EVIDENCE: Staff enable service users to take part in activities which they enjoy and in which they are able to participate. These activities are assessed in personcentered plans and in review meetings. Daily records show that service users are free to join in the activity or not as they wish. They make good use of community facilities including shops, church, pubs and restaurants. Service users are also supported to maintain links with family and friends and to develop personal relationships, where possible. Fenwick Road, 29 DS0000007096.V317981.R01.S.doc Version 5.2 Page 11 Service users went on a holiday to Centre Parc this year, although this was not included as part of the basic contract price. Service users also went on holiday singly, with other groups to which they belong. However it still seems that activities outside the home, especially in the evenings, are not of a sufficient level. For instance one service user enjoys going to a club but only goes once a month. Her review brought up the need for more activities, but these have not been accessed yet although the manager is exploring options. Staff are knowledgeable about the food that service users like, and a service user was seen enjoying a snack. The supper menu is varied and nutritious; however the lunch menu seemed to rely too much on food that had little nutritious value and there were many ”pot noodles” in the kitchen which staff said were being used for lunches although they were not on the menu. One service user had put on a lot of weight which is not in her best interests and the home needs to take advice as to how best to provide tasty food which service users will like but which is nutritious and suitable for their individual needs. Fenwick Road, 29 DS0000007096.V317981.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 health needs are met and their well being protected by good medication administration procedures. Personal care is given in an appropriate manner. EVIDENCE: Care plans showed good knowledge of service’ users preferences on how they should be looked after. The father of a service user confirmed that the care given to his daughter was good and delivered in a proper manner. Care plans also show that referrals are made as necessary to speech or occupational therapists. Health care needs were well documented and monitored and evidence was available to show that referrals had been made as necessary and appointments kept. Medication administration was extremely well recorded with information on each service user’s drugs available on the chart. Fenwick Road, 29 DS0000007096.V317981.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 adequate. This judgement has been made using available evidence including a visit to this service. The organisations policy on dealing with allegations of abuse does not protect service users. Although complaints handled well, the complaints policy is not in an accessible format. EVIDENCE: A complaint that had been noted in a service user’s file had been properly recorded, investigated and dealt with in the home’s complaints’ file. The commission has received no complaints about the home. The home’s complaints policy has not yet been put into a format accessible for this service user group, although the manager is working towards this. The organisation has a policy for dealing with allegations of abuse. However the section on what to do if there is abuse is not in line with legislation and the organisation must take advice and must change the policy as soon as possible. The manager has copies of the local borough’s vulnerable adults policy and Department of Health guidelines on dealing with vulnerable adults. Staff have been on training for working with vulnerable adults. Fenwick Road, 29 DS0000007096.V317981.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): 24,26,27,29,30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have a comfortable, safe, clean home which is well adapted to their needs. EVIDENCE: The home’s environment continues to meet the needs of service users well. It is well sited for transport and local facilities and is in keeping with the other homes in the street. There is a pleasant, accessible garden to the rear. Service users each have their own bedroom, which are of good size and extremely well personalised for them to enjoy. Communal areas are ample downstairs and there is a sensory room on the top floor. One service user has an en suite bathroom and other bathrooms are welcoming and well equipped. Adaptations needed to maximise independence are assessed for and provided. The whole home is well decorated, bright and comfortable and on the day of inspection was clean and safe. It was also hygienic except for the laundry walls which are still not of a washable material. Fenwick Road, 29 DS0000007096.V317981.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): 32,35,36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users receive good support from experienced and well-trained staff. EVIDENCE: There is a long-standing staff group who know service users well and so are able to give them consistent care. Of these staff, 50 are now trained to NVQ level 3 standard and three more are working towards this qualification. Supervision and appraisal systems are in place to enable staff to work to their potential. As there have been no new staff since the last inspection the home’s recruitment policies could not be checked. There is a good training programme which covers most areas needed for this service user group and it is commendable that bank staff are also offered training opportunities. Staff have been on training to learn signing to facilitate better communication. Further training, specific to working with service users with learning difficulties could further enhance their skills. Fenwick Road, 29 DS0000007096.V317981.R01.S.doc Version 5.2 Page 16 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is well managed and safe although moving and handling training needs to be updated annually. A formalised system of quality monitoring and annual development would mean that service users could be sure that their views were fully taken into account in planning the service. EVIDENCE: The manager is experienced both in management and with this service user group and she is now supported by a knowledgeable deputy. She has undertaken the NVQ 4 in management. Quality monitoring is still be undertaken by monthly person in control visits and questionnaires to relatives and other agencies. These initiatives still need to be formalised into an effective quality monitoring system where all interested parties views are taken, findings are analysed and an annual report published. There also needs to be a formalised annual development plan. The Fenwick Road, 29 DS0000007096.V317981.R01.S.doc Version 5.2 Page 17 manager reported that a new post has been recruited to in the organisation and these issues should form part of the work of the new post holder. Health and safety systems for the home were seen to be in order except for moving and handling training which is not being up-dated yearly. Fenwick Road, 29 DS0000007096.V317981.R01.S.doc Version 5.2 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 X 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 3 28 X 29 3 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 X 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 2 X Fenwick Road, 29 DS0000007096.V317981.R01.S.doc Version 5.2 Page 19 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA13 Regulation 16(2)(m)(n) Requirement The registered person must ensure that all service users have a full programme of social activities, worked out with them and their relatives or advocates. Target dates of 30/10/05 and 30/06/06 not met The registered person must ensure that food is nutritious and suitable for service users’ individual dietary needs. The registered person must ensure that the complaints policy is in a format accessible to the service users. (This requirement has been amended as other work detailed in it has been completed) Target dates of 30/09/05 and 30/06/06 not met. The registered person must ensure that the policy for dealing with allegations of abuse conforms to legislation. The registered person must ensure that the laundry walls are made of washable material. DS0000007096.V317981.R01.S.doc Timescale for action 31/03/07 2. YA17 16(2)(i) 31/03/07 3. YA22 22(2) 31/03/07 4. YA23 13(6) 31/12/06 5. YA30 13(3) 31/03/07 Fenwick Road, 29 Version 5.2 Page 20 6. YA39 24 7. YA42 13(5) Target dates of 31/12/ 05 and 30/06/06 not met. The registered person must 31/03/07 ensure that there is an effective quality monitoring system and annual development plan. Target date of 30/08/06 not met. The registered person must 31/12/06 ensure that training for all staff on Moving and Handling is updated annually. 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 YA1 YA14 YA35 Good Practice Recommendations It is recommended that the statement of purpose and service users guide are in a format accessible to this service user group It is recommended that a seven-day annual holiday is included in the basic contract price. It is recommended that the home consider training specific to delivering care to service users with learning disabilities. Fenwick Road, 29 DS0000007096.V317981.R01.S.doc Version 5.2 Page 21 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. Extracts may not be used or reproduced without the express permission of CSCI Fenwick Road, 29 DS0000007096.V317981.R01.S.doc Version 5.2 Page 22 - 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!