Inspection on 24/06/05 for Fenwick Road, 29

This inspection was carried out on 24th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Fenwick Road, 29 30/10/08

Fenwick Road, 29 01/11/06

Fenwick Road, 29 07/01/06

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 29 Fenwick Road London SE15 4HS Lead Inspector Pam Cohen Unannounced 24 June 2005, 9:30 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. 29 Fenwick Road G52-G02 S7096 FenwickRoad 234999 240605 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 29 Fenwick Road Address London SE15 4HS 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 7732 5261 020 7732 5261 Saffronland Homes Mariam Moshood CRH care home PC care home only 3 Category(ies) of LD learning disability registration, with number of places 29 Fenwick Road G52-G02 S7096 FenwickRoad 234999 240605 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 24 February 2005 Brief Description of the Service: The home provides care for three adults with learning difficulties. It is managed by the Saffronlands group. 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 availability. On the day of the visit there were no vacancies. 29 Fenwick Road G52-G02 S7096 FenwickRoad 234999 240605 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place during a period when the manager of the home was on sick leave and the deputy manager had left. Staff on duty showed the inspector round, answered her questions and showed her documentation. The service user in the home at the time of inspection was not able to verbalise and so could not give her views. What the service does well: What has improved since the last inspection? What they could do better: Staff are working to ensure as much communication as possible with service users. This work needs to be ongoing and to look at areas of documentation such as the service users’ guide and complaints policy. The provision of social 29 Fenwick Road G52-G02 S7096 FenwickRoad 234999 240605 stage 4.doc Version 1.30 Page 6 activities outside of the home needs to be looked at again with an eye to providing as varied a social life as possible. Staff training to NVQ standards is also needed. 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. 29 Fenwick Road G52-G02 S7096 FenwickRoad 234999 240605 stage 4.doc Version 1.30 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 29 Fenwick Road G52-G02 S7096 FenwickRoad 234999 240605 stage 4.doc Version 1.30 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, 3 The home is conducted in a way that ensures that the assessed needs of service users are met. The format of the statement of purpose and service users’ guide are innappropriate for this service user group. EVIDENCE: The home has an up-to-date statement of purpose and service users’ guide. These need to be in a format that service users who are unable to communicate in written English can understand. Evidence from staff and documentation showed that the needs of service users are met. 29 Fenwick Road G52-G02 S7096 FenwickRoad 234999 240605 stage 4.doc Version 1.30 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) 6,9, Care planning and risk assessments are both good and ensure that service users’ needs can be met as safely as possible. EVIDENCE: Care plans seen, were detailed and service users’ needs were well documented. Service users, their advocates or relatives are involved in reviewing and updating their care needs. There is a thorough system of risk assessment which could be followed through from planning an action to assessing and minimising the risk. 29 Fenwick Road G52-G02 S7096 FenwickRoad 234999 240605 stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11,12,13,17 There are good opportunities for service users to maintain and develop as much independence as possible. The social activities programme could be more creative. The dietary needs of service users was not being well planned in the short term. EVIDENCE: Service users living in the home have differing needs and are all helped to become as independent as possible at their own level; areas covered include communication and food preparation. Where needed service users are helped to go to religious services of their choice. All service users go to college and are helped to access the courses they want to follow. One service user who wanted to do a cookery course is now doing this. Individual activity plans show that one service user has a full programme, whilst the other two are able to do less. Activities for these service users, accompanied by staff include shopping, cinema, going to the pub and local walks. There is scope for a more varied social life, for example regular visits to a social club, which at the moment is not happening. The visit was held on a hot day in June and there was still a winter menu in operation. As a consequence this was not being followed in an effort to offer 29 Fenwick Road G52-G02 S7096 FenwickRoad 234999 240605 stage 4.doc Version 1.30 Page 11 more seasonal food. This meant that aspects of nutrition and balance had not been worked out and, for instance, take aways had been on the menu for two days running. 29 Fenwick Road G52-G02 S7096 FenwickRoad 234999 240605 stage 4.doc Version 1.30 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) 18,19,20 The home looks after the personal care and health needs of its service users well. EVIDENCE: Detailed care plans and a staff group that know the service users well, mean that personal care can be given in a personalised and sensitive way. Care plans also showed that the health care needs of service users are well assessed and monitored with appropriate liaison with health care professionals. The area of medication was covered by the CSCI’s pharmacy inspector in January and found to be of a good standard. The requirements that she left at the time have now been met . 29 Fenwick Road G52-G02 S7096 FenwickRoad 234999 240605 stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 23,24 A complaint that had been recorded was well dealt with, which indicates that service users views are listened to. The complaints policy,however, is not in an accessible format for this service user group. Arrangements for protecting vulnerable adults are good. EVIDENCE: There was one complaint logged in the complaints book which had been well investigated and recorded. The complaints policy still needs updating with the CSCI contact details and the information that they can be contacted at any time. It also needs to be in a format accessible to service users. The home has an appropriate policy for protecting vulnerable adults and staff training in this area has been updated. 29 Fenwick Road G52-G02 S7096 FenwickRoad 234999 240605 stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25,27,28,30 Service users have a comfortable home with all facilities needed. EVIDENCE: The home is suitable for the service user group although only partially wheelchair accessible. It is homely and well maintained internally. There is an ongoing problem with cracked walls and subsidence which is at the moment in the hands of the insurers. Service users’ rooms are spacious, well furnished and reflect their interests and there are ample bathing and toilet facilities. The communal living room and dining room is big enough and the garden, which leads off it, was being used, as the day was sunny. There is an office off the living room which can be used for private meetings. The home was clean and systems for keeping it hygienic were in place. The laundry has a new floor but has walls which are not washable. 29 Fenwick Road G52-G02 S7096 FenwickRoad 234999 240605 stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,36. A well supported staff group who are clear about their roles are able to give consistent care to the service users. Insufficient numbers of staff trained to NVQ standard means that service users do not benefit from qualified staff. EVIDENCE: Staff have job descriptions and in conversation were clear about their roles and responsibilities. The rota showed that there are two staff on in the day and one at night which is sufficient for the three service users. Only two out of seven staff have NVQ’s which does not reach the National Minimum Standard of 50 of the staff group. Staff said that they have regular supervision and annual appraisals. They also said that they are confident that their views are heard by their line managers. 29 Fenwick Road G52-G02 S7096 FenwickRoad 234999 240605 stage 4.doc Version 1.30 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 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) 38, 42, There is a positive atmosphere and good systems to ensure service users’ safety. Some action however needs to be taken in relation to dangerous substances. EVIDENCE: Staff said that the manager is friendly and supportive and ensures that there is a good atmosphere in the home. Health and safety in the home was seen to be dealt with well except for the care of dangerous chemicals. Some of these were out in the laundry which is accessible to service users. The COSHH cupboard also needs to be labelled. 29 Fenwick Road G52-G02 S7096 FenwickRoad 234999 240605 stage 4.doc Version 1.30 Page 17 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 3 x x Standard No 22 23 ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 x 3 3 x 2 Standard No 11 12 13 14 15 16 17 3 3 2 x x x 2 Standard No 31 32 33 34 35 36 Score 3 2 3 x x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 29 Fenwick Road Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x 3 x x x 2 x G52-G02 S7096 FenwickRoad 234999 240605 stage 4.doc Version 1.30 Page 18 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 13 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. The registered person must ensure that seasonal food is provided and that nutrition is ensured without undue reliance on take aways. The registered person must ensure that there is an up-todate complaints policy, with all information required by legislation, and in a format accessible to the service users. The registered person must continue to make all efforts to ensure that the cracks in the exterior of the home are repaired. They must contact the CSCI with information as soon as they have a time-scale for repairs. The previous timescale of 30th September 2004 was not met. The registered person must ensure that the laundry walls are made of washable material The registered person must ensure that a training plan is Timescale for action 30th September 2005 31st August 2005 30th September 2005 2. 17 16(2)(i) 3. 22 22 4. 24 23(2)(b) 31st October 2005 5. 6. 30 32 13(3)) 18(1)(a)T 31st December 2005 31st October Page 19 29 Fenwick Road G52-G02 S7096 FenwickRoad 234999 240605 stage 4.doc Version 1.30 7. 42 13(4)(a) produced which provides for at least 50 of staff to hold an NVQ qualification. The registered person must ensure that all substances hazardous to health are properly stored in a labelled cupboard. 2005 31st August 2005 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 1 Good Practice Recommendations The registered person should ensure that the statement of purpose and service users guide is in a format accessible tio this service user group 29 Fenwick Road G52-G02 S7096 FenwickRoad 234999 240605 stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection 46 Loman Street London SE1 0EH 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 29 Fenwick Road G52-G02 S7096 FenwickRoad 234999 240605 stage 4.doc Version 1.30 Page 21 - 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. 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